The YTM® Tool Method for infants is a prescribed protocol of exercises designed to support oral and orofacial function. It considers the relationship between the mouth, facial structures, fascia, soft tissues and the wider body, recognising that feeding involves coordinated movement and function rather than the tongue acting in isolation. The infant protocol uses the principles of release, lengthening and restoration. Its prescribed exercises are intended to address identified functional needs, which may include fascial tension and mobility, tissue length and movement, muscle tone, strength and coordination, sensory input, lymphatic flow and drainage, and oral and facial function (D-Restricted Ltd, 2026). The YTM® Tool is a specialised intraoral instrument developed by Yulli Tamayo-Myerson, founder of Myofunctional Therapy UK, and is used for some exercises within the infant protocol. The method encompasses the prescribed programme as a whole, rather than simply the use of the physical tool (Myofunctional Therapy UK, 2025). The YTM® Infant and SEN Protocol is one of the distinct protocols within the wider YTM® system. It is specifically adapted to infant anatomy, development and care and should not be confused with protocols intended for older children or adults (TBIOM®, n.d.). What is the YTM® Tool Method for infants? The YTM® Tool Method is a structured programme delivered following individual assessment. It combines prescribed exercises with professional guidance, caregiver participation and ongoing monitoring of progress. The method considers how oral and facial function may be influenced by soft-tissue mobility, fascial tension, movement patterns, muscle function and sensory input. Rather than concentrating solely on one structure, the infant protocol considers these factors within the context of the infant's wider body and functional needs. The principles of release, lengthening and restoration inform the approach. The exercises prescribed depend on the findings of the assessment and the goals established for the individual infant. The programme is suitable for infants up to two years of age, including infants with special educational needs (SEN), where the approach is appropriate to their presentation and clinical needs. TBIOM® (The British Institute of Orofacial Myology) offers professional training in the YTM® Method, including a dedicated Infant and SEN Protocol. Its Level 3 Certificate in the Professional YTM® Method for Infants focuses on techniques adapted to infant anatomy, development and care (TBIOM®, n.d.). Assessment, goal setting and monitoring Assessment is central to the YTM® Tool Method. Before exercises are prescribed, the practitioner considers the infant's overall presentation, feeding function and relevant developmental and neurological factors. This helps establish which areas may benefit from support and provides a basis for setting meaningful goals. Depending on the infant's presentation, assessment includes the following interconnected areas. Full-body assessment A full-body assessment considers movement, posture, soft-tissue mobility and areas of tension throughout the infant's body. This wider assessment reflects the relationship between the oral structures and the surrounding musculoskeletal and fascial systems. Fascia is connective tissue that surrounds and connects structures throughout the body. Its mobility is relevant to how tissues move in relation to one another. The method incorporates techniques intended to address fascial tension and mobility where these are relevant to the infant's identified functional needs. A full-body perspective does not mean assuming that every feeding difficulty originates outside the mouth, or that a particular area of tension necessarily causes an oral or feeding problem. It provides a broader context in which to consider the infant's presentation and the relationships between bodily functions. Feeding assessment Feeding assessment considers how the infant functions during feeding, rather than relying solely on oral anatomy or the appearance of the tongue. Depending on whether the infant is breastfed, bottle-fed, combination-fed or receiving expressed milk, relevant observations may include positioning, attachment where applicable, sucking patterns, oral seal, coordination, swallowing, feeding efficiency, fatigue and the experience of the feeding dyad. The assessment also considers the caregiver's concerns, what is working well, the support already received and the outcomes that matter most to the family. Where a feeding difficulty may have several contributing factors, these need to be considered rather than attributing the problem automatically to tongue-tie, fascial tension or muscle tone. Neurological assessment Neurological assessment considers relevant aspects of the infant's neurological presentation and function. Depending on the clinical context, this may include movement, muscle tone, reflex responses, sensory responses and coordination. These observations help inform the practitioner's understanding of the infant's presentation and whether further assessment or referral is needed. They also help ensure that prescribed exercises are appropriate to the infant's developmental and clinical needs. The findings from these assessments inform the goals agreed for the programme. Progress is monitored throughout the six sessions, with reassessment at the final evaluation session to establish what has changed and whether the original goals have been achieved. Goal setting is therefore not simply an initial discussion. It provides a reference point for reviewing the infant's progress and deciding whether further support, maintenance or referral is appropriate. What do the prescribed exercises address? The infant YTM® Tool Method incorporates exercises intended to support several related aspects of orofacial function. Fascial tension and mobility: Techniques are intended to support soft-tissue mobility and address areas of fascial tension identified during assessment. Tissue length and movement: Prescribed exercises may support tissue mobility and movement patterns relevant to oral and facial function. Muscle tone, strength and coordination: Exercises are selected to support the functional use and coordination of the oral and facial musculature where these are identified as areas requiring attention. Sensory input and neuromuscular re-education: The protocol incorporates specific sensory and movement-based input intended to support functional movement patterns and the coordination of oral structures. Lymphatic flow and drainage: The method includes techniques intended to support lymphatic flow where relevant to the assessment findings. Oral and facial function: The exercises are selected according to the areas of function identified as requiring support, including those relevant to feeding. Fascia connects structures throughout the body, so the relationships between different areas of function need to be considered as part of the overall assessment. An infant's presentation should not be understood by looking at individual structures in isolation. The prescribed protocol reflects the individual assessment and goals, rather than assuming that every infant presents with the same pattern of needs (D-Restricted Ltd, 2026). The relationship between tongue-tie restriction and the YTM® Tool Method Tongue-tie, or ankyloglossia, describes a lingual frenulum that restricts tongue movement and may contribute to functional difficulties. However, the presence or appearance of a frenulum alone does not establish whether an infant has a clinically significant restriction. Tongue movement and feeding function need to be considered alongside the infant's presentation and the caregiver's experience (Academy of Breastfeeding Medicine, 2021). A restrictive lingual frenulum may be one factor affecting oral function. Restricted movement can influence how an infant uses the tongue during feeding, but feeding difficulties may also involve other oral, muscular, sensory, developmental or feeding-related factors. The YTM® Tool Method is not designed solely for infants with tongue-tie. It provides a structured programme of prescribed exercises intended to support identified aspects of orofacial function. Where tongue-tie restriction is present, the method may complement tongue-tie division by supporting neuromuscular re-education of the muscles and oral structures following the procedure. Outcomes cannot be guaranteed, and the appropriateness of the programme depends on the infant's individual assessment and goals. The method and surgical division have different purposes. Frenulotomy divides the restrictive lingual frenulum when a clinical assessment indicates that the procedure may be appropriate. The YTM® Tool Method is a prescribed exercise protocol intended to support orofacial function. It is not a substitute for tongue-tie division where the procedure is clinically indicated, and the presence of tongue-tie does not automatically mean that surgical division is necessary. At D-Restricted Ltd®, two distinct programmes are available: Tension & Tone: a six-session programme using the YTM® Tool Method without surgical tongue-tie division. Tongue-tie, Tension & Tone: a six-session programme combining tongue-tie assessment and, where indicated and consented to, surgical division with the YTM® Tool Method. The decision about whether to divide a tongue-tie is made through clinical assessment in session 1 and discussion of the potential benefits, risks and alternatives. The goals of the exercise programme remain individual to the infant, whether or not a procedure forms part of the care plan. Where the infant's presentation indicates that further investigation or a different type of support is needed, referral to an appropriate specialist service may be recommended. The role of the caregiver Caregivers have an active role in the infant YTM® Tool Method. Following assessment and professional instruction, the caregiver completes the prescribed exercises with the infant three times per day throughout the programme. The exercises are demonstrated and explained by the practitioner. The caregiver receives the relevant instructions and can refer to the exercise information within the infant's patient profile between appointments. The YTM® Tool is used for the exercises for which it is prescribed; other exercises within the protocol do not require the tool. Regular participation allows the prescribed programme to continue between sessions. The caregiver should follow the instructions provided and contact the practitioner if clarification is needed or if concerns arise about the infant's response. The caregiver's role is not limited to completing a set of exercises. The programme also creates opportunities for attentive, responsive interaction between caregiver and infant. Gentle, guided interaction can support positive connection and bonding, while allowing the caregiver to become more familiar with the infant's responses and cues. The exercises should remain appropriate to the infant's comfort and presentation, with the quality of the interaction taking precedence over simply completing a prescribed task. The structure of the infant programme At D-Restricted Ltd®, the infant programme consists of six sessions delivered over ten weeks, with approximately two weeks between sessions. Individual goals are established at the outset, and targeted exercises are prescribed according to the assessment findings. The caregiver completes the exercises three times daily, and progress is reviewed throughout the programme. At the final evaluation session, the practitioner reassesses the infant's current function and reviews progress against the original goals. This helps determine whether the goals have been achieved, whether further work is appropriate, or whether another form of support or referral should be considered. Maintenance exercises may be discussed where appropriate. An optional review appointment is also available following completion of the programme. What can families expect? The YTM® Tool Method provides a structured approach to supporting identified aspects of infant orofacial function through assessment, goal setting, prescribed exercises and monitoring. The programme considers oral function in the context of the infant's wider body and feeding experience, with active caregiver participation between appointments. The intended outcomes depend on the infant's individual presentation and the goals established at the beginning of the programme. Families should receive clear explanations of what the exercises are intended to address, how progress will be monitored and what the available evidence can and cannot establish. The method is described as research-informed and draws on principles relating to movement, muscle function, sensory input and neuromuscular re-education. However, evidence supporting individual principles or related interventions should not automatically be interpreted as proof that the complete YTM® Infant and SEN Protocol has been shown to produce specific clinical outcomes. Where feeding difficulties persist, further assessment or referral may be appropriate. The programme should remain responsive to the infant's needs, with goals and prescribed exercises reviewed in light of progress. No particular outcome can be guaranteed. The central principle is that the infant YTM® Tool Method combines an individual assessment with a prescribed exercise protocol, regular caregiver participation and monitoring of functional goals. It considers the infant as a whole, while keeping the intervention focused on the specific areas identified during assessment. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. D-Restricted Ltd (2026) YTM® Tool Method. Available at: https://www.tongue-tie.info/ytm. Myofunctional Therapy UK (2025) The YTM® Tool and Method. Available at: https://www.myofunctionaltherapy.co.uk/ytm-tool-method (consulted 14 October 2026). TBIOM® (n.d.) Level 3 Certificate in the Professional YTM® Method for Infants. Available at: https://www.t-biom.com/accreditedytminfantmethodcertificate (consulted 14 October 2026).

Torticollis and infant feeding: understanding head preference, neck movement and feeding function Torticollis is a condition in which an infant's head tilts to one side, often with the chin turned towards the opposite side. It can be associated with restricted neck movement, muscular tightness or a preference for looking in one direction. Some infants with torticollis experience difficulties with breastfeeding or bottle feeding, particularly when a feeding position requires them to turn towards a less-preferred side. Feeding involves more than the mouth. The head, neck, jaw, tongue, lips and cheeks work together with breathing, swallowing and postural control. When an infant has restricted movement or asymmetry, it may be helpful to consider how these factors interact during feeding. However, torticollis does not automatically cause feeding difficulties, and feeding problems should not be attributed to head position alone. A thorough assessment considers the infant's movement, oral function, feeding method, milk transfer and the comfort of the feeding dyad. What is torticollis? The term torticollis describes an abnormal head position, usually involving a tilt to one side and rotation towards the opposite side. It is a clinical sign rather than a single diagnosis, and the underlying cause needs to be considered. Congenital muscular torticollis is commonly identified during the first weeks or months of life. It involves tightness or shortening of the sternocleidomastoid muscle, which runs along each side of the neck. The muscle helps rotate and tilt the head, so differences in its length or function can affect the infant's range of movement. Not every infant with a preferred head position has muscular torticollis. Some have a positional preference without clear muscle tightness or restricted passive movement. Other causes of an abnormal head position may also need consideration. The Royal Children's Hospital Melbourne (2020a) describes both muscular and postural presentations and recommends assessment of head position, neck movement, craniofacial asymmetry and the infant's wider clinical presentation. A head-turning preference may be noticeable during everyday activities, including being carried, lying on the floor, looking towards a caregiver or feeding. Some infants can turn comfortably in both directions but consistently choose one side; others have a more obvious restriction in movement. The distinction matters because the appropriate management depends on the findings. A positional preference, muscular torticollis and an acquired or acute-onset head position should not automatically be treated as the same condition. How can torticollis affect infant feeding? An infant needs to bring their mouth comfortably towards the breast or bottle, open their mouth, establish an effective attachment and coordinate sucking, swallowing and breathing. Head and neck movement can influence how easily they achieve and maintain that position. When an infant has restricted neck movement or a consistent head-turning preference, feeding may be easier in one position than another. This can be particularly noticeable during breastfeeding because the infant's approach to each breast differs according to the position used. Watson Genna (2015) describes how muscular tension and associated craniofacial, spinal and hip asymmetries may contribute to breastfeeding difficulties in some infants with congenital torticollis. The article discusses positioning adaptations and support for comfortable movement as part of lactation care, alongside referral for physiotherapy when indicated. These observations do not mean that every infant with torticollis will struggle to feed. Some feed effectively without additional support, while others may have difficulties that require a more detailed assessment. Breastfeeding and chestfeeding Breastfeeding requires the infant to achieve an effective attachment and coordinate tongue, jaw and other oral movements to remove milk. The position of the head and neck can influence how comfortably the infant approaches the breast and maintains that attachment. An infant who consistently turns towards one side may find one breastfeeding position easier than another. Families may notice that the infant attaches readily to one breast but struggles on the other, repeatedly loses attachment, turns away or appears uncomfortable when positioned in a particular direction. Some infants may feed well in one position but find another difficult. This can make the difference between positions a useful observation during assessment. It is important not to assume that difficulty feeding from one breast means that the breast itself is the problem, or that the infant necessarily has a tongue-tie. The infant's head position, neck movement, oral function, latch, milk flow and the feeding parent's comfort all need to be considered. My article on Breastfeeding Latch and Positioning discusses how the infant's position and freedom to move their head can influence attachment. How to Improve Infant Latch: Practical Breastfeeding Support also explores the factors that can affect an effective latch. A feeding assessment can help establish whether changing the infant's position makes attachment easier, whether the infant can maintain a comfortable latch and whether milk transfer appears effective. Where there are ongoing difficulties, skilled breastfeeding support may be useful alongside assessment of neck movement. Bottle feeding and torticollis Bottle feeding also requires coordination between the infant's mouth, jaw, tongue, head and neck. Although the feeding method differs from breastfeeding, the infant still needs to maintain a comfortable position while sucking, swallowing and breathing. An infant with restricted neck movement may find it difficult to maintain a comfortable head position during a bottle feed. Families might notice that the infant settles more readily when held on one side, turns their head away from the teat, struggles to maintain a seal or appears less comfortable in a particular feeding position. These signs are not specific to torticollis. Similar behaviours may occur for several reasons, including difficulties with milk flow, teat characteristics, oral function, feeding coordination, discomfort or previous stressful feeding experiences. The position used for bottle feeding is therefore worth considering as part of the assessment. The infant should be well supported, with their head and neck in a comfortable position that allows them to breathe and swallow without restriction. They should not be forced to turn their head against their preferred movement or held in a position that appears uncomfortable. My article on Bottle Feeding Positions explains how positioning can be adapted while keeping the infant's comfort and feeding cues central to the feed. How to Pace Bottle Feeds: A Calm, Practical Guide discusses responsive pacing and recognising when an infant needs a pause. The bottle and teat should also be considered. Teat shape, flow and the way the infant attaches can affect feeding mechanics, although no particular teat can correct torticollis or guarantee effective feeding. Choosing Bottles and Teats explores these considerations, while Choosing the Best Bottles for Tongue-tied Infants considers bottle-feeding choices where oral restriction is also being assessed. Where tongue movement is restricted, an infant may have difficulty maintaining a seal or coordinating oral movements. Bottle Feeding With Tongue Restriction discusses these possible difficulties. Torticollis and tongue-tie may coexist, but neither diagnosis should be assumed from the other. If an infant begins refusing a bottle, becomes increasingly distressed or accepts progressively less milk, it is important to consider the full feeding history rather than assuming that head position explains the behaviour. My article When Your Baby Suddenly Refuses the Bottle discusses possible reasons for a change in bottle-feeding behaviour. Sucking, swallowing and breathing Effective feeding requires coordination between sucking, swallowing and breathing. The infant must manage milk flow while maintaining a safe and sustainable pattern of oral movement and respiration. Research into breastfeeding mechanics has used ultrasound and other methods to investigate tongue movement, intra-oral vacuum and milk transfer (Geddes and Sakalidis, 2016; Sakalidis and Geddes, 2016). These studies help explain the complexity of feeding, although findings from breastfeeding research should not automatically be applied to every bottle-feeding situation. Head and neck position may be relevant to feeding comfort and coordination, but the presence of torticollis alone does not establish that an infant has a swallowing or respiratory problem. During an observed feed, it may be useful to consider whether the infant maintains a comfortable position, attaches effectively, sustains sucking, pauses appropriately and appears able to coordinate breathing with swallowing. Persistent coughing, choking, colour changes, breathing difficulty or repeated episodes of distress during feeds require appropriate clinical assessment rather than simply changing the feeding position. Bottle-feeding research also highlights that the feeding method involves interactions between the infant, the caregiver and the equipment used (Kotowski et al., 2020). A teat's flow characteristics, the way the bottle is held and the caregiver's response to the infant's cues may all influence the feeding experience. Where an infant appears to swallow excessive air or needs frequent pauses, the cause should not automatically be attributed to torticollis. My article How to Wind a Baby During and After Feeds provides further information about winding, while Recognising Feeding Cues in Young Babies explores how infants communicate their readiness to feed, need for a pause and signs of having had enough. The relationship between the head, neck and jaw The jaw and the surrounding oral structures contribute to attachment, suction and milk transfer. The mandible, or lower jaw, needs to move in coordination with the tongue, lips and cheeks during feeding. An infant with restricted neck movement may adopt compensatory positions to bring their mouth towards the breast or teat. In some cases, the head position may also influence the apparent alignment of the jaw or the ease with which the infant opens their mouth. Wall and Glass (2006) described mandibular asymmetry in a small case series involving breastfeeding difficulties. Such reports can help clinicians recognise possible relationships between asymmetry and feeding, but a case series cannot establish that one feature causes another or that the same pattern occurs in every infant. It is useful to observe how the infant's head, jaw and mouth move together during feeding rather than treating these structures as separate systems. However, an apparent asymmetry does not automatically indicate a structural abnormality, and it should be interpreted in the context of the infant's age, movement, feeding function and clinical assessment. My articles Infant Oral Anatomy: Structure, Function and Feeding and A Guide to Understanding Your Baby’s Oral Function explore the relationship between oral structures and feeding mechanics. Torticollis, head shape and positional asymmetry Some infants with torticollis also develop positional plagiocephaly, which describes asymmetrical flattening of the skull. Brachycephaly describes a relatively broad, short head shape, often associated with flattening across the back of the head. When an infant consistently rests or turns their head in one direction, pressure may be concentrated on the same area of the skull. Restricted neck movement and a preferred head position may therefore be relevant when considering head shape and movement together. The Royal Children's Hospital Melbourne (2020a) includes craniofacial asymmetry among the features that may be seen in congenital muscular torticollis. The relationship between head shape, neck movement and feeding is not straightforward, however. Positional flattening does not, by itself, demonstrate that feeding is impaired, and feeding difficulties do not establish that skull shape is responsible. My article Infant Skull Shape and Infant Feeding discusses how head shape, jaw position and feeding mechanics may be considered together without assuming a direct causal relationship. Families should follow safer-sleep guidance and place infants on their backs for sleep, on a firm, flat surface. Advice about awake-time positioning, supervised tummy time and encouraging comfortable head movement should be appropriate to the infant's age and development and should not compromise safe sleep. What might families notice? The signs associated with torticollis vary. Some families notice a head-turning preference before feeding difficulties become apparent; others seek feeding support first and only later recognise that their infant consistently prefers one direction. Observations that may be useful to discuss with a healthcare professional include: consistently turning the head towards one side; difficulty turning comfortably in the opposite direction; a persistent head tilt; finding one breastfeeding position easier than another; appearing less comfortable when bottle fed in a particular position; repeatedly losing attachment or struggling to maintain a seal; visible asymmetry of the head or face; difficulty settling into certain feeding positions. None of these observations alone establishes a diagnosis or identifies the cause of a feeding difficulty. They are useful pieces of information to include in a wider assessment. Families may find it helpful to note whether the infant's feeding changes with position, whether the same pattern occurs at the breast and bottle, and whether the infant appears comfortable between feeds. A short video of a typical feeding position may sometimes help a healthcare professional understand what the family is observing, provided it is recorded safely and does not delay assessment when there are urgent concerns. Assessment and management Assessment should consider the infant's head position, neck range of movement, muscle function, general movement, development and any associated asymmetry. The healthcare professional should also consider whether the presentation is consistent with congenital muscular torticollis or whether another cause needs to be investigated. The Royal Children's Hospital Melbourne (2020a) recommends that infants with suspected congenital muscular torticollis receive appropriate clinical assessment. Physiotherapy referral may be indicated where movement is restricted, the presentation is more severe or improvement is limited. The management plan depends on the infant's clinical findings. A feeding assessment is complementary to, rather than a replacement for, assessment of neck movement. It may involve observing a breast or bottle feed, considering the infant's position and attachment, and assessing sucking, swallowing, breathing, milk transfer and the comfort of the feeding dyad. Where an infant has difficulty feeding, it is important to consider the impact on intake, hydration and growth. Concerns about poor milk transfer, reduced urine output, lethargy, persistent feeding distress or faltering weight gain require timely clinical review. A sudden onset of torticollis, a head position associated with significant pain, fever, unusual drowsiness, neurological symptoms or other signs of acute illness should not be assumed to be congenital muscular torticollis. Such presentations need prompt medical assessment. The Royal Children's Hospital Melbourne (2020b) provides guidance on acquired torticollis and the importance of considering other causes. Physiotherapy and body therapy Physiotherapy can play an important role in the management of congenital muscular torticollis. Paediatric physiotherapists assess the infant's movement and may provide guidance on positioning, handling, appropriate exercises and opportunities to develop comfortable movement. The 2024 evidence-based clinical practice guideline from the American Physical Therapy Association Academy of Pediatric Physical Therapy sets out recommendations for the assessment and management of congenital muscular torticollis (Sargent et al., 2024). Management should be guided by the infant's individual presentation and delivered by an appropriately qualified practitioner. Families sometimes also explore other hands-on or body-based approaches when an infant has asymmetry, muscular tension or feeding difficulties. These approaches do not all have the same evidence base, scope of practice or proposed mechanism. Evidence for one intervention should not be treated as evidence for another, and a change in posture or perceived tension does not, by itself, demonstrate improved feeding function. Any body-based approach should be considered in the context of the infant's clinical needs, with appropriate professional qualifications, clear consent and safe handling. It should not delay medical assessment or recommended physiotherapy. There is also no reason to assume that every infant with torticollis needs additional hands-on treatment. Body therapy does not replace an assessment of feeding. Where a family is concerned about attachment, milk transfer, bottle acceptance or feeding comfort, these aspects need to be assessed directly. The role of an infant feeding specialist and IBCLC An infant feeding specialist can assess feeding mechanics and help identify whether the infant's head position or movement appears to affect feeding. Depending on the practitioner's qualifications and scope of practice, this may include observing breastfeeding or bottle feeding, considering attachment and positioning, assessing oral function and discussing responsive feeding strategies. An International Board Certified Lactation Consultant (IBCLC) can provide specialist lactation care, including assessment of breastfeeding difficulties and support for families who are expressing milk or combining feeding methods. An IBCLC may also work alongside other healthcare professionals where an infant has torticollis or another condition affecting feeding. A feeding assessment should not be limited to finding a position that appears easier. It should also consider whether the infant is transferring milk effectively, whether the feeding parent or caregiver is comfortable, and whether the feeding plan is sustainable for the family. Further information is available in What Does an Infant Feeding Specialist Do?, What Is an IBCLC? Feeding Support Explained and Lactation Support: What Does a Lactation Consultant Do?. Is tongue-tie related to torticollis? Tongue-tie, or ankyloglossia, describes a lingual frenulum that restricts tongue movement and is associated with functional difficulty. It is a separate consideration from torticollis, which concerns head position and neck movement. Some infants may have both conditions, and both may be relevant to feeding assessment. However, the presence of torticollis does not establish that an infant has tongue-tie, and tongue-tie should not be diagnosed solely because an infant has difficulty latching, prefers one feeding position or has facial asymmetry. Where tongue restriction is suspected, assessment should consider the infant's tongue structure and function alongside a detailed feeding history and observation of feeding. The aim is to determine whether restricted tongue movement is contributing to the functional difficulty, rather than attributing all feeding problems to the appearance of the frenulum. My article What Does a Tongue-tie Assessment Consider? explains the factors that may be considered during assessment. Where a division has been performed, Beyond a Tongue-tie Release: Why Aftercare Matters discusses follow-up and feeding support. The article Tongue-tie Release Exercises provides further information about exercises and oral movement. A tongue-tie procedure does not treat torticollis. If restricted neck movement is present, it needs its own assessment and appropriate management. Similarly, addressing torticollis does not necessarily resolve feeding difficulties that have another contributing cause. Supporting the feeding dyad When an infant has torticollis alongside feeding difficulties, support is most useful when it responds to the needs of that individual feeding dyad. There is no single position or intervention that will suit every infant. Practical support may include: identifying feeding positions that allow the infant to remain comfortable without forcing neck movement; observing attachment, sucking, swallowing and breathing during an actual feed; reviewing bottle-feeding position, pacing and teat characteristics where relevant; assessing oral function when feeding difficulties indicate that this is appropriate; arranging physiotherapy or medical assessment when neck movement is restricted or the clinical presentation warrants it; monitoring feeding effectiveness, milk intake and growth; coordinating care between the relevant healthcare professionals. For some families, a small change in positioning may be enough to improve comfort. Others may need a combination of feeding support, physiotherapy and medical follow-up. The plan should be guided by assessment and reviewed in response to the infant's progress. Where breastfeeding is difficult, families should not be left feeling that they must repeatedly try new positions without understanding why feeding is uncomfortable or ineffective. Where bottle feeding is difficult, the response should not automatically be to change the bottle or teat without considering the infant's movement, oral function, feeding cues and overall clinical presentation. The aim is to understand what is happening during feeding and to identify support that is appropriate to the cause of the difficulty. Conclusion Torticollis and positional preference can be relevant to infant feeding because head and neck movement contribute to the position in which an infant attaches to the breast or teat. Some infants find feeding easier on one side or in one position, while others feed effectively despite an observable head preference. The presence of torticollis does not automatically mean that feeding will be affected, and feeding difficulties should not be attributed to torticollis, tongue-tie or any other single factor without appropriate assessment. Considering head and neck movement alongside oral function, feeding mechanics, milk transfer and the infant's wider clinical presentation can help families and practitioners understand what support may be needed. Where restricted neck movement is present, appropriate clinical assessment and physiotherapy may be important. Where feeding difficulties coexist, skilled infant-feeding support can help the feeding dyad work towards comfortable and effective feeding. References Geddes, D.T. and Sakalidis, V.S. (2016) ‘Ultrasound imaging of breastfeeding—a window to the inside: Methodology, normal appearances, and application’, Journal of Human Lactation, 32(2), pp. 340–349. Available at: https://doi.org/10.1177/0890334415626152. Kotowski, J., Fowler, C., Hourigan, C. and Orr, F. (2020) ‘Bottle-feeding an infant feeding modality: An integrative literature review’, Maternal & Child Nutrition, 16(2), e12939. Available at: https://doi.org/10.1111/mcn.12939. Royal Children's Hospital Melbourne (2020a) ‘Clinical practice guidelines: Congenital torticollis’. Available at: https://www.rch.org.au/clinicalguide/guidelineindex/CongenitalTorticollis/. Royal Children's Hospital Melbourne (2020b) ‘Clinical practice guidelines: Acquired torticollis’. Available at: https://www.rch.org.au/clinicalguide/guidelineindex/Acquiredtorticollis/. Sakalidis, V.S. and Geddes, D.T. (2016) ‘Suck-swallow-breathe dynamics in breastfed infants’, Journal of Human Lactation, 32(2), pp. 201–211. Available at: https://doi.org/10.1177/0890334415601093. Sargent, B., Coulter, C., Cannoy, J. and Kaplan, S.L. (2024) ‘Physical therapy management of congenital muscular torticollis: A 2024 evidence-based clinical practice guideline from the American Physical Therapy Association Academy of Pediatric Physical Therapy’, Pediatric Physical Therapy, 36(4), pp. 370–421. Available at: https://doi.org/10.1097/PEP.0000000000001114. Wall, V. and Glass, R. (2006) ‘Mandibular asymmetry and breastfeeding problems: Experience from 11 cases’, Journal of Human Lactation, 22(3), pp. 328–334. Available at: https://doi.org/10.1177/0890334406290096. Watson Genna, C. (2015) ‘Breastfeeding infants with congenital torticollis’, Journal of Human Lactation, 31(2), pp. 216–220. Available at: https://doi.org/10.1177/0890334414568315.

Tongue-tie assessment involves more than identifying a lingual frenulum or assigning a score to its appearance. The clinical question is whether the tongue’s structure and movement are restricted in a way that may affect feeding, and whether the findings are consistent with the difficulties experienced by the infant and feeding dyad. Several tools are used by healthcare professionals to assess infant tongue-tie, also known as ankyloglossia. They differ in their assessment criteria, the functions they examine and the evidence supporting their use. Some concentrate on anatomical appearance, some assess tongue movement, and others incorporate a broader range of oral function or feeding-related observations. Understanding these differences is important because a tool can help to structure an assessment without necessarily establishing the cause of feeding difficulties or predicting the outcome of frenulotomy. A score is one part of the clinical picture, not a substitute for clinical reasoning. The systematic review by Necus et al. (2025) identified nine assessment tools used in infants from birth to 12 months and found variation in their content and supporting evidence. This highlights the continuing challenge of identifying a consistent, reliable approach to assessing tongue-tie in infants. For further information, see What does a tongue-tie assessment consider? and How is tongue-tie assessed in babies safely?. The distinction between appearance and function The lingual frenulum is a normal anatomical structure. Its appearance varies between individuals, and visible differences do not automatically indicate a functional restriction. Conversely, the appearance of the frenulum alone may not fully describe how the tongue moves during feeding. Ankyloglossia is generally understood as a congenital condition in which the lingual frenulum restricts tongue movement. However, there is no universally accepted definition or single assessment method that establishes the clinical significance of every presentation (Messner et al., 2020; Thomas et al., 2024). A comprehensive assessment considers several related areas: Anatomy: the appearance of the lingual frenulum and its relationship to the tongue and floor of the mouth. Function: the tongue’s ability to elevate, extend, lateralise and move in ways relevant to feeding. Feeding impact: whether observed feeding difficulties are consistent with the functional findings, taking account of the wider feeding dyad. These areas need to be considered together. A visible frenulum, a particular attachment point or a numerical score cannot independently establish that tongue-tie is responsible for feeding difficulties. Hatami et al. (2022), in a systematic review of tongue-tie assessment tools, found limitations in the evidence supporting the use of assessment classifications to determine which infants would benefit from frenotomy. Identifying an anatomical variation, classifying its severity and deciding whether an intervention is clinically indicated are related but different tasks. Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF/ATLFF) The Hazelbaker Assessment Tool for Lingual Frenulum Function, also referred to as the Assessment Tool for Lingual Frenulum Function (ATLFF), was developed by Alison Hazelbaker. It assesses both the appearance of the lingual frenulum and aspects of tongue function. The tool includes anatomical features as well as functional items such as lateralisation, lift and extension of the tongue, alongside observations relating to sucking. Its broader structure is intended to provide more information than an assessment based on the frenulum’s appearance alone. Amir, James and Donath (2006) examined the reliability of the Hazelbaker tool. They reported good agreement between assessors for several functional items, although agreement was weaker for some appearance items. Their findings illustrate why the reliability of individual assessment components matters when interpreting a total score. The HATLFF/ATLFF has also been used as a comparison tool during the development of other assessment methods. However, its use as a reference does not establish that every tool correlated with it can independently predict feeding outcomes or the need for frenulotomy (Hatami et al., 2022). Bristol Tongue Assessment Tool (BTAT) The Bristol Tongue Assessment Tool was developed by Ingram et al. (2015) to provide a simpler, structured way of assessing tongue-tie in infants. The BTAT assesses four features: The appearance of the tongue tip. The attachment of the lingual frenulum to the lower gum ridge. Tongue elevation. Tongue protrusion. Each item contributes to the overall score, allowing the assessor to record findings consistently. Importantly, Ingram et al. (2015) state that the BTAT was developed from clinical practice with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function. The authors compared the BTAT with the ATLFF in a group of infant assessments and reported a strong correlation between the tools, alongside acceptable internal reliability and good consistency between assessors using the BTAT. These findings supported the BTAT as a practical, shorter assessment method. They do not demonstrate that a BTAT score alone can identify the cause of feeding difficulties or reliably predict which infants will benefit from frenulotomy. The 2026 systematic review and meta-analysis by Dhar et al. reported high discriminative accuracy for the BTAT and TABBY when identifying ankyloglossia. However, the authors rated the overall certainty of evidence as very low. The distinction between identifying a restrictive lingual frenulum and establishing its functional impact therefore remains important. Tongue-tie and Breastfed Babies Assessment Tool (TABBY) The Tongue-tie and Breastfed Babies Assessment Tool, known as TABBY, was developed by Ingram et al. (2019) as a pictorial version of the BTAT. TABBY uses illustrations to represent the same four assessment areas: tongue-tip appearance, frenulum attachment, elevation and protrusion. Its visual format is intended to make the assessment criteria easier to understand and apply consistently. The score ranges from 0 to 8, with lower scores indicating greater restriction according to the tool’s scoring system. The illustrations can help assessors communicate the features being observed, but the score still needs to be interpreted alongside the infant’s function and feeding assessment. Ingram et al. (2019) evaluated TABBY in clinical practice and reported high agreement between TABBY and BTAT scores. Agreement between two related tools is useful evidence of consistency, but it is not the same as demonstrating that either tool can predict feeding outcomes or the response to frenulotomy. The 2026 review by Dhar et al. considered BTAT and TABBY together and reported promising diagnostic discrimination, while emphasising the very low certainty of the overall evidence. These findings support structured assessment rather than using a score in isolation to determine treatment. Lingual Frenulum Protocol for Infants (LFPI) The Lingual Frenulum Protocol for Infants, developed by Martinelli and colleagues, provides a more comprehensive assessment framework. It incorporates a range of anatomical and functional observations and includes information relating to sucking and feeding. The original protocol was described by Martinelli, Marchesan and Berretin-Felix (2012). It has two parts: a clinical history, including questions about family history and breastfeeding, and a clinical examination incorporating anatomical and functional assessment alongside non-nutritive and nutritive sucking observations. Martinelli et al. (2016) subsequently published validation work on the protocol. Its broader scope is relevant when considering the relationship between oral structure, tongue movement and feeding function. Necus et al. (2025) identified the LFPI as the most comprehensive of the tools included in their review and reported that it had the greatest amount of reported reliability and validity evidence among the tools they examined. This should not be interpreted as proof that it is a definitive diagnostic standard. The review identified limitations in the evidence base across the available tools, and the comprehensiveness of a protocol does not automatically establish its ability to predict clinical outcomes. The LFPI illustrates the difference between a brief screening or classification tool and a more extensive assessment protocol. The appropriate approach depends on the clinical question, the assessor’s competence and the wider assessment of the infant and feeding dyad. Coryllos classification The Coryllos classification describes the anatomical location and pattern of lingual frenulum attachment. It divides tongue-tie into four types, from attachment at the tip of the tongue to attachment further underneath the tongue or towards its base. It is an anatomical classification rather than a numerical score of tongue function. The four types are commonly described as follows: Type I: the frenulum attaches at or very close to the tip of the tongue. The attachment may be associated with a heart-shaped appearance when the tongue is extended. Type II: the frenulum attaches approximately 2–4 mm behind the tongue tip, on or near the alveolar ridge. Type III: the frenulum attaches around the middle of the underside of the tongue and the middle of the floor of the mouth. Type IV: the frenulum attaches towards the base of the tongue and may be deep or submucosal, making it less readily visible on inspection. Types I and II are generally described as anterior presentations, while types III and IV are often discussed in relation to posterior tongue-tie. The term posterior tongue-tie is itself subject to debate, and the presence of a less visible frenulum does not independently establish functional restriction (Messner et al., 2020; Thomas et al., 2024). Unlike the BTAT or HATLFF/ATLFF, Coryllos classification does not assign points to several assessment items and produce a total score. The assessor assigns an anatomical type according to the attachment observed or palpated. The classification can therefore help describe the anatomical finding, but it does not measure the degree of restriction during feeding or establish whether the infant’s difficulties are caused by the frenulum. A type should not be interpreted as a direct measure of clinical severity or as an indication for frenulotomy. Kotlow classification The original Kotlow classification grades tongue-tie according to the measured length of the free portion of the tongue. This is the distance from the tongue tip to the point where the lingual frenulum attaches to the underside of the tongue. Kotlow (1999) proposed four classes based on this measurement, with shorter free-tongue length assigned a higher grade. The commonly reported original categories are: | Kotlow classification | Free tongue length | Description | |---|---:|---| | Within the stated normal range | More than 16 mm | Normal free-tongue length according to this classification | | Class I | 12–16 mm | Mild ankyloglossia | | Class II | 8–11 mm | Moderate ankyloglossia | | Class III | 3–7 mm | Severe ankyloglossia | | Class IV | Less than 3 mm | Complete ankyloglossia | These measurements describe the anatomical length of the free portion of the tongue. They do not directly measure the tongue’s ability to elevate, extend, lateralise or maintain the movements needed for effective feeding. It is important not to confuse Kotlow’s original length-based classification with modified grading systems that classify the position of the frenulum’s attachment in relation to the tongue tip. Modified systems may use different class boundaries and measurement criteria; the version being used should therefore be identified rather than treating all Kotlow grading systems as interchangeable. Obtaining a consistent measurement in an infant may also be challenging, particularly when tongue movement is restricted or the attachment point is difficult to identify. The classification should be understood as an anatomical description, not a comprehensive functional assessment. Kotlow’s original paper, ‘Ankyloglossia (tongue-tie): a diagnostic and treatment quandary’ (1999), proposed diagnostic criteria and a classification method. The use of a measurement to grade anatomy does not, by itself, establish whether frenulotomy is indicated or predict the likely feeding outcome. Comparing tongue-tie assessment tools | Tool | Main focus | Important consideration | |---|---|---| | HATLFF/ATLFF | Appearance and several aspects of tongue function, including sucking-related observations | A broader tool, but reliability varies between individual items | | BTAT | Four structured anatomical and movement items | Developed with reference to the ATLFF; a score does not independently establish feeding impact | | TABBY | Pictorial assessment of the same four areas as BTAT | Visual format may support consistent scoring; it does not replace clinical assessment | | LFPI | Broader anatomical and functional assessment, including sucking and feeding-related information | More comprehensive, although limitations remain in the evidence base | | Coryllos | Four types based on the location and characteristics of frenulum attachment | Describes anatomical type rather than providing a comprehensive functional score | | Kotlow | Original classification uses four grades based on measured free-tongue length | A measurement-based anatomical grade does not directly assess feeding function | The tools differ in purpose and scope, so they should not be treated as interchangeable. A tool designed primarily to classify anatomy answers a different question from a protocol that includes functional observations. Similarly, a tool’s reported reliability does not necessarily establish its validity for predicting feeding outcomes. Feeding assessment alongside tongue-tie assessment Tongue movement and feeding function need to be considered together. A structured tongue assessment can document anatomical features and movement, but it cannot replace an assessment of the feeding dyad. For breastfeeding, relevant observations may include attachment, positioning, milk transfer, sucking patterns, swallowing, maternal comfort and the sustainability of feeding. For bottle feeding, the assessment may also consider the infant’s oral seal, sucking pattern, coordination, flow tolerance and signs of feeding difficulty. The particular observations required depend on the infant and the reported concerns. The assessment also needs to consider other factors that may contribute to feeding difficulties. These can include positioning, feeding technique, milk flow, oral-motor function, infant state, discomfort and wider health or developmental considerations. The presence of a lingual frenulum does not establish that it is the cause of every feeding difficulty. An assessment should therefore explore the reported difficulties, observe feeding where appropriate and relate those findings to the tongue’s functional movement. This helps distinguish the identification of an anatomical variation from the clinical judgement that the variation is contributing to a feeding problem. Further reading includes What does an infant feeding specialist do?, What is an IBCLC? Feeding Support Explained and Lactation support: What does a Lactation Consultant do?. Training, competence and diagnostic responsibility Using an assessment tool consistently requires an understanding of its purpose, scoring criteria and limitations. Professionals also need to recognise when findings are unclear, when further assessment is needed and when feeding difficulties may have more than one contributing factor. Training can support consistent use of an assessment tool, but familiarity with a scoring system does not automatically establish competence in every aspect of tongue-tie assessment or frenulotomy. Practitioners need to work within their professional scope, training and governance arrangements, and should be familiar with the evidence and guidance relevant to their clinical role. The terms and conditions associated with individual tools may also differ. Professionals should check the relevant publication, permissions and training requirements rather than assuming that every tool has the same conditions for reproduction or teaching. Where frenulotomy is being considered, the practitioner responsible for the procedure must reach an appropriate clinical decision based on their assessment, the infant’s presentation and the feeding concerns. A score should not be used as the sole justification for a procedure. For further information, see What 'Tongue-tie School' teaches healthcare professionals and Tongue-tie training for evidence-based care. Integrating assessment findings into clinical decisions The Academy of Breastfeeding Medicine (2021) describes ankyloglossia as a functional diagnosis and states that the presence of a sublingual frenulum alone is not an indication for frenotomy. The clinical decision needs to consider whether there is a functional restriction associated with breastfeeding difficulties and whether appropriate support has addressed potentially modifiable factors. The American Academy of Pediatrics clinical report by Thomas et al. (2024) similarly emphasises the importance of a comprehensive assessment of feeding difficulties and consideration of other causes before intervention. These recommendations reinforce the distinction between anatomical identification and a decision about treatment. Assessment tools can help professionals record findings, communicate with colleagues and monitor changes over time. Their value depends on using them for the purpose for which they were developed and interpreting their findings in context. A clinical decision should bring together the infant’s oral anatomy, tongue movement, observed feeding, the concerns described by the feeding dyad and the response to appropriate feeding support. Where the findings do not align, further assessment may be needed rather than allowing a numerical score to determine the outcome. For related information, see Does my baby need a tongue-tie release?, When feeding doesn't feel right: Looking beyond tongue-tie and Tongue-tie: understanding assessment, feeding, treatment and aftercare. 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. Amir, L.H., James, J.P. and Donath, S.M. (2006) ‘Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function’, International Breastfeeding Journal, 1, article 3. doi: 10.1186/1746-4358-1-3. Dhar, V. et al. (2026) ‘Diagnostic Assessment of Ankyloglossia and Association With Infant Feeding Challenges: A Systematic Review and Meta-Analysis—Part 1’, Pediatric Dentistry, 48(2), pp. 68E–82E. Hatami, A., Dreyer, C.W., Meade, M.J. and Kaur, S. (2022) ‘Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review’, Australian Dental Journal, 67(3), pp. 212–219. doi: 10.1111/adj.12921. 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–F349. doi: 10.1136/archdischild-2014-307503. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2019) ‘The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY)’, International Breastfeeding Journal, 14, article 31. doi: 10.1186/s13006-019-0224-y. Kotlow, L.A. (1999) ‘Ankyloglossia (tongue-tie): a diagnostic and treatment quandary’, Quintessence International, 30(4), pp. 259–262. Martinelli, R.L.C., Marchesan, I.Q. and Berretin-Felix, G. (2012) ‘Lingual frenulum protocol with scores for infants’, International Journal of Orofacial Myology, 38(1), pp. 104–112. doi: 10.52010/ijom.2012.38.1.8. Martinelli, R.L.C., Marchesan, I.Q., Gusmão, R.J., Honório, H.M. and Berretin-Felix, G. (2016) ‘Validation of the Lingual Frenulum Protocol for Infants’, International Journal of Orofacial Myology, 42(1), pp. 5–13. doi: 10.52010/ijom.2016.42.1.1. Messner, A.H. et al. (2020) ‘Clinical consensus statement: Ankyloglossia in children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. doi: 10.1177/0194599820915457. Necus, E., Claessen, M., Hennessey, N. and Smart, S. (2025) ‘Assessment of tongue structure and function in infants for the diagnosis of ankyloglossia: A systematic review’, International Journal of Pediatric Otorhinolaryngology, 196, article 112485. doi: 10.1016/j.ijporl.2025.112485. Thomas, J. et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 154(2), article e2024067605. doi: 10.1542/peds.2024-067605.

Infant feeding involves coordinated movement throughout the body. Whether an infant feeds at the breast or from a bottle, effective feeding requires the tongue, jaw, lips, cheeks, head and neck to work together, alongside breathing, swallowing, postural stability and the ability to maintain a comfortable, regulated state. Feeding difficulties are not always explained by milk supply, feeding equipment or oral anatomy alone. Muscular tension, restricted movement, asymmetry and difficulties coordinating oral movements may also influence how an infant attaches, maintains a seal, generates suction and transfers milk. Body-based therapies are sometimes used alongside skilled infant-feeding support to address musculoskeletal restrictions and movement patterns that may contribute to feeding difficulties. These approaches include physiotherapy, osteopathy, cranial osteopathy, craniosacral therapy and chiropractic care. Orofacial myofunctional therapy is another related discipline, although it is generally more appropriate for older children and adults who can participate actively in instructed exercises. Understanding the relationship between oral function, muscular tension and infant movement helps families and practitioners consider which forms of assessment and support may be useful. Birth, movement and infant feeding Infants adapt to movement and positioning throughout pregnancy, birth and early development. Their feeding skills also develop as they gain experience coordinating sucking, swallowing and breathing. Some infants demonstrate a preference for turning their head to one side, difficulty maintaining a comfortable feeding position, asymmetrical jaw movement or differences in their ability to attach to each breast. Others may struggle to maintain a deep latch, sustain suction or coordinate their oral movements efficiently. These observations can have several contributing factors. An assessment of infant feeding therefore benefits from considering the feeding mechanism alongside the infant's movement, posture, oral function and the circumstances of the feeding dyad. A body-based assessment may identify restrictions or asymmetries that warrant attention. This can complement a detailed feeding assessment, which considers attachment, sucking, swallowing, milk transfer and feeding comfort. The Association of Tongue-tie Practitioners (ATP) discusses the relationship between manual therapy and infant feeding in its manual therapy and infant feeding guidance. Its infant-feeding support information also provides further context for families seeking feeding support. Tongue-tie and oral muscle function The tongue plays a central role in feeding. Its movement contributes to attachment, maintenance of a seal, suction generation, milk transfer and the coordination of swallowing. Effective tongue function depends on more than the appearance of the tongue or its ability to protrude. A lingual frenulum is a normal anatomical structure beneath the tongue. When its structure restricts tongue movement and is associated with functional difficulties, the condition is commonly described as tongue-tie, or ankyloglossia. Research into the lingual frenulum has demonstrated its close relationship with the connective tissues of the floor of the mouth. Mills et al. (2020) examined the histological structure of the frenulum and floor-of-mouth fascia, describing the frenulum as a fold involving fascia and overlying oral mucosa. The study also identified variation in fascial thickness and tissue composition. Martinelli et al. (2014) investigated the histological characteristics of altered lingual frenulum tissue in children undergoing frenulum surgery. A restrictive frenulum may limit the tongue's ability to elevate, extend or move efficiently during feeding. An infant may compensate by changing jaw movement, recruiting other oral muscles differently or adopting an alternative feeding pattern. These compensations may affect the wider mechanics of feeding. Research following frenotomy has examined changes in both breastfeeding function and oral muscle activity. Santos et al. (2023) assessed 20 infants before and seven days after lingual frenotomy. The researchers reported improvements in breastfeeding assessment categories, including positioning, latch and sucking, alongside a reduction in the measured electrical activity of the masseter muscle. This provides an example of research examining both feeding outcomes and the activity of muscles involved in feeding after division. A tongue-tie is a structural restriction. Osteopathy, chiropractic care, physiotherapy and craniosacral therapy do not divide or remove the frenulum. Where a restrictive frenulum has contributed to altered movement or muscular compensation, body-based therapy may be considered as part of support for residual tension and movement patterns. Assessment for tongue-tie and decisions about whether division is appropriate remain separate clinical considerations. Further information is available in Choosing Your Tongue-tie Practitioner and Tongue-tie Release in England: UK CQC Requirements. Information about exercises discussed following tongue-tie division is available in Tongue-tie Release Exercises. Muscular tension, fascia and whole-body movement Muscles do not work in isolation. They are surrounded and connected by connective tissues, including fascia, which relates to structures such as tendons, ligaments and other supporting tissues. These tissues help support movement, transmit forces and allow structures to glide in relation to one another. Fascial anatomy has been explored extensively by Thomas Myers in Anatomy Trains, which describes proposed myofascial continuities between different regions of the body (Myers, 2020). Systematic reviews have examined the anatomical basis of these connections. Wilke et al. (2016) reviewed anatomical evidence for proposed myofascial chains and found strong support for some chains, with varying levels of support for others. Krause et al. (2016) examined evidence for force transmission along myofascial chains and found evidence of tension transfer between some connected structures. These findings provide a framework for considering how movement and tension may relate across connected tissues. The anatomical relationships are relevant to manual and movement-based approaches that consider the body as an interconnected system. Connective tissue can also change following injury, inflammation, surgery and tissue healing. Collagen is an important component of connective tissue, and its organisation and composition contribute to tissue strength and mechanical behaviour. Martinelli et al. (2014) investigated collagen characteristics in altered lingual frenulum tissue, while Mills et al. (2020) examined the histological structure of the frenulum and floor-of-mouth fascia. The relevance to infant feeding is that oral tissues, muscles and connective tissues operate together. A restrictive oral structure may influence local movement, and an infant may develop compensatory patterns in response to restricted movement or discomfort. These changes can be considered alongside the movement of the jaw, head and neck when assessing feeding. A whole-body assessment considers these relationships rather than assuming that every feeding difficulty originates at the breast, bottle or tongue. The purpose is to identify movement patterns or restrictions that may be contributing to the individual infant's presentation and consider appropriate support. The jaw and feeding mechanics The mandible, or lower jaw, is the only freely movable bone of the facial skeleton. Its movement is important for attachment, jaw stability and the coordination of the tongue and other oral structures during feeding. At the breast, the infant needs to maintain an effective attachment while coordinating tongue and jaw movement to generate the pressure changes involved in milk transfer. Geddes et al. (2008) investigated tongue movement and intra-oral vacuum during breastfeeding, demonstrating the importance of oral movement and pressure generation in milk removal. Bottle-feeding also requires coordinated oral movement and suction, although the flow characteristics of the teat and the feeding position influence how the infant manages the feed. Restricted jaw movement, asymmetry or excessive muscular effort may affect the infant's ability to maintain a comfortable and effective feeding pattern. Some infants demonstrate differences in how widely they open their mouth, how their jaw moves during sucking or how consistently they maintain a seal. The relationship between the stomatognathic system and body posture has been discussed in the literature, including by Cuccia and Caradonna (2009). In infant feeding, it is useful to consider jaw movement alongside tongue function, head position and the infant's overall comfort rather than assessing these structures in isolation. Facial asymmetry may also be observed alongside differences in head position or movement. These observations need to be interpreted in the context of the infant's development and clinical presentation. Torticollis Torticollis describes a head position in which the head tilts to one side, often with the chin turned towards the opposite side. Congenital muscular torticollis can involve tightness or shortening of the sternocleidomastoid muscle, although head-position preferences may have other causes. An infant who finds it difficult to turn comfortably in one direction may struggle to achieve a consistent feeding position. This can affect attachment at one breast, positioning during bottle-feeding or the infant's ability to maintain a comfortable posture while feeding. Watson Genna (2015) described how muscular and craniofacial asymmetry associated with congenital torticollis may influence breastfeeding mechanics. Positioning adjustments and support for comfortable movement can help the feeding dyad, while paediatric physiotherapy can assess and manage torticollis. Families may be able to request an NHS paediatric physiotherapy referral through their GP. The appropriate pathway depends on local services and the infant's needs. Skull shape Infant skull shape can influence how the head rests against a surface and how comfortably an infant turns and positions their head. Positional plagiocephaly describes asymmetrical flattening of the skull, while brachycephaly describes a relatively broad, short head shape with flattening at the back. Skull shape, head-turning preferences and neck movement may be considered together when an infant presents with feeding difficulties or positional asymmetry. An assessment of skull shape does not, by itself, explain a feeding problem, but it may provide useful context when considered alongside movement and oral function. Further discussion is available in Infant Skull Shape and Infant Feeding. Advice about sleep positioning remains important. Infants should be placed on their backs for every sleep, on a firm, flat surface, following current safer-sleep guidance (BASIS, n.d.; The Lullaby Trust, n.d.). Families can find further information from BASIS and The Lullaby Trust. Any advice about awake-time positioning or movement should be consistent with safe-sleep recommendations. Osteopathy and cranial osteopathy Osteopathy is a regulated healthcare profession in the UK. Osteopaths use clinical assessment and manual approaches to consider movement, function and musculoskeletal presentation. Cranial osteopathy is an approach practised by some osteopaths that uses gentle manual contact to assess and work with movement and tension. In the context of infant feeding, an osteopath may consider the movement of the head, neck, jaw and associated soft tissues, as well as the infant's general comfort and posture. The intended focus may include musculoskeletal restrictions or compensatory patterns that could make positioning or oral movement more difficult. Osteopathy does not release a restrictive lingual frenulum. Where tongue-tie has contributed to restricted movement or compensatory tension, osteopathic care may be considered alongside appropriate tongue-tie assessment and infant-feeding support. Research has investigated osteopathic treatment alongside lactation care. Herzhaft-Le Roy, Xhignesse and Gaboury (2017) conducted a randomised controlled trial involving 97 mother–infant dyads with biomechanical sucking difficulties. The study found statistically and clinically significant differences in LATCH assessment scores between the group receiving osteopathic treatment alongside lactation consultations and the control group. It did not find a significant difference in nipple-pain scores between groups. Fons et al. (2025) reported a pilot randomised controlled trial involving 40 healthy, full-term breastfed newborns with feeding dysfunction. The study examined osteopathic manipulative treatment alongside lactation support and reported greater improvement in feeding assessment in the treatment group. Chen et al. (2026) reviewed the literature on osteopathic manipulative treatment for the breastfeeding dyad. Their scoping review identified 35 studies, including 19 with feeding-related outcomes. The authors concluded that preliminary evidence suggests osteopathic manipulative treatment may support feeding-related outcomes and identified a need for further interdisciplinary research. The General Osteopathic Council maintains the statutory register of osteopaths in the UK. Families can use its register search to check a practitioner's registration. Chiropractic care and gentle manual approaches Chiropractic is a regulated profession in the UK. Chiropractors assess and manage musculoskeletal presentations using approaches that may include manual techniques, movement advice and soft-tissue work. The approach used with an infant should be appropriate to the infant's age, presentation and needs. Where an infant has restricted movement, positional asymmetry or muscular tension, a chiropractor may assess the musculoskeletal contribution to the presentation. The relevance of this approach to feeding depends on the individual assessment and the way any intervention is delivered. Chiropractic care does not treat or divide a restrictive lingual frenulum. It may be considered as a complementary approach where musculoskeletal factors are also being addressed, alongside direct assessment of feeding and oral function. The General Chiropractic Council (GCC) is the statutory regulator for chiropractors in the UK. Families can find information about registration and professional standards through the GCC website. Physiotherapy Physiotherapy can be relevant when an infant has restricted neck movement, torticollis, asymmetrical movement, postural difficulties or other musculoskeletal concerns. Paediatric physiotherapists assess movement and function and may use positioning, handling, movement activities and other appropriate interventions to support development. Where a feeding difficulty occurs alongside torticollis or a clear movement asymmetry, physiotherapy may help address the movement component while an infant-feeding practitioner assesses attachment, sucking, swallowing and milk transfer. Families can ask about NHS paediatric physiotherapy services through local healthcare pathways. Some families may also choose to access private paediatric physiotherapy. The Health and Care Professions Council (HCPC) maintains the statutory register for physiotherapists in the UK. Registration can be checked through the HCPC website. Craniosacral therapy Craniosacral therapy is a hands-on approach that uses gentle contact and is practised by some therapists working with infants. Practitioners may focus on perceived restrictions or tension and the infant's comfort and movement. Families considering this approach in relation to feeding may wish to understand the practitioner's training, experience with infants and approach to working alongside other professionals. Craniosacral therapy is distinct from cranial osteopathy, which is practised by osteopaths registered with the General Osteopathic Council. The Craniosacral Therapy Association provides information about its profession and practitioners through its website. Myofunctional therapy Orofacial myofunctional therapy focuses on the function and coordination of the muscles of the mouth and face. Depending on the individual, work may address tongue posture, lip seal, oral movement, swallowing patterns and related functional habits. Most structured myofunctional programmes are designed for school-aged children, adolescents or adults who can understand instructions and actively practise exercises. They are therefore not generally a direct substitute for infant-feeding assessment or hands-on support for a young infant who cannot follow instructed exercises. For older children and adults, myofunctional therapy may be relevant where oral function, tongue posture or swallowing patterns need further assessment and support. Suitability depends on the presenting concern and the practitioner's clinical scope. The British Society of Myofunctional Therapy (BSMFT) provides information about orofacial myofunctional therapy and its practitioners through its website. What does the research say? Research on body-based approaches to infant feeding includes randomised controlled trials, observational studies and reviews. Some studies have reported improvements in feeding assessments when osteopathic treatment is provided alongside lactation support. Herzhaft-Le Roy et al. (2017) found improved LATCH scores in the group receiving osteopathic treatment alongside usual lactation consultations. Fons et al. (2025) also reported greater improvement in feeding assessment in the treatment group in a pilot randomised controlled trial. The 2026 scoping review by Chen et al. brings together published research on osteopathic manipulative treatment for the breastfeeding dyad. Research into tongue-tie and oral muscle function also helps explain why feeding can involve changes beyond the frenulum itself. Santos et al. (2023) reported improved breastfeeding assessment scores following frenotomy alongside a change in masseter muscle activity. Histological studies by Martinelli et al. (2014) and Mills et al. (2020) provide further information about the structure of the lingual frenulum and its relationship with floor-of-mouth tissues. Research on myofascial chains provides a basis for considering connections between muscles and connective tissues in different parts of the body. Wilke et al. (2016) reviewed anatomical evidence for proposed myofascial chains, while Krause et al. (2016) examined evidence for force transmission along connected structures. Together, these areas of research support continued investigation of the relationship between oral function, movement, connective tissue and feeding. They also provide a rationale for considering the infant's presentation as a whole, rather than assuming that every feeding difficulty has a single cause. Infant-feeding support Body-based therapy is most useful to consider within a wider assessment of the feeding dyad. A feeding assessment can examine attachment, oral function, sucking patterns, swallowing, milk transfer, feeding comfort and the practical circumstances of breast or bottle feeding. An infant-feeding specialist may help identify the feeding difficulties that need attention and coordinate support with other relevant professionals. More information is available in What Does an Infant Feeding Specialist Do?. An International Board Certified Lactation Consultant (IBCLC) has completed the relevant international certification process and can provide specialist lactation care. IBCLCs can assess breastfeeding and help families consider feeding strategies, positioning, milk transfer and other factors affecting the feeding dyad. Read more in What Is an IBCLC? Feeding Support Explained. Families can search for an IBCLC through the Lactation Consultants of Great Britain directory or find information about certification and the international registry through IBLCE. Further information about lactation support is available on the D-Restricted lactation page. For bottle-feeding families, the choice of bottle and teat, feeding position and pacing can also influence the feeding experience. Further information is available in Choosing Bottles and Teats and How to Pace Bottle Feeds: A Calm, Practical Guide. The appropriate combination of support depends on the infant's needs. Some families benefit from feeding advice alone; others may need assessment of oral function, musculoskeletal movement or both. UK practitioner registers and directories The following organisations provide information about professional registration or practitioner directories. Statutory regulators and professional associations have different roles, so checking a practitioner's status should include consideration of their registration, training, scope of practice and experience with infants. Physiotherapy: the Health and Care Professions Council (HCPC) maintains the statutory register for physiotherapists. Osteopathy and cranial osteopathy: the General Osteopathic Council (GOsC) maintains the statutory register for osteopaths. Cranial osteopathy is an approach practised by some registered osteopaths. Chiropractic: the General Chiropractic Council (GCC) regulates chiropractors in the UK. Craniosacral therapy: the Craniosacral Therapy Association provides information about the profession and its practitioners. Orofacial myofunctional therapy: the British Society of Myofunctional Therapy provides information about the profession and practitioners. Tongue-tie assessment and division: the Association of Tongue-tie Practitioners provides information about tongue-tie practice and professional standards. Its guidance can be considered alongside Choosing Your Tongue-tie Practitioner. In England, providers carrying out regulated activities must meet the relevant Care Quality Commission (CQC) requirements. Further information about tongue-tie release and the regulatory context is available in Tongue-tie Release in England: UK CQC Requirements. References BASIS (n.d.) Safer sleep information. Available at: https://www.basisonline.org.uk/ Chen, A.I. et al. (2026) ‘Osteopathic manipulative treatment for the breastfeeding dyad: a scoping review’, Journal of Human Lactation, 42(3), pp. 595–619. doi: 10.1177/08903344261430249. Cuccia, A. and Caradonna, C. (2009) ‘The relationship between the stomatognathic system and body posture’, Clinical Anatomy, 22(5), pp. 556–565. Fons, D. et al. (2025) ‘Osteopathic manipulative treatment for management of feeding dysfunction in breastfed newborns’, Journal of Osteopathic Medicine, 126(8), pp. 383–391. doi: 10.1515/jom-2024-0133. 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. doi: 10.1016/j.earlhumdev.2007.12.008. Herzhaft-Le Roy, J., Xhignesse, M. and Gaboury, I. (2017) ‘Efficacy of an osteopathic treatment coupled with lactation consultations for infants’ biomechanical sucking difficulties: a randomized controlled trial’, Journal of Human Lactation, 33(1), pp. 165–172. doi: 10.1177/0890334416679620. Krause, F., Wilke, J., Vogt, L. and Banzer, W. (2016) ‘Intermuscular force transmission along myofascial chains: a systematic review’, Journal of Anatomy, 228(6), pp. 910–918. doi: 10.1111/joa.12464. Martinelli, R.L.C., Marchesan, I.Q., Gusmão, R.J., Rodrigues, A.C. and Berretin-Felix, G. (2014) ‘Histological characteristics of altered human lingual frenulum’, International Journal of Pediatrics and Child Health, 2(1), pp. 5–9. doi: 10.12974/2311-8687.2014.02.01.2. Mills, N., Geddes, D.T., Amirapu, S. and Mirjalili, S.A. (2020) ‘Understanding the lingual frenulum: histological structure, tissue composition, and implications for tongue tie surgery’, International Journal of Otolaryngology, 2020, article 1820978. doi: 10.1155/2020/1820978. Myers, T.W. (2020) Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 4th edn. Elsevier. Santos, H.K.M.P. de S. et al. (2023) ‘Effects of lingual frenotomy on breastfeeding and electrical activity of the masseter and suprahyoid muscles’, CoDAS, 35(2), e20210262. doi: 10.1590/2317-1782/20232021262. The Lullaby Trust (n.d.) Safer sleep overview. Available at: https://www.lullabytrust.org.uk/baby-safety/safer-sleep-information/safer-sleep-overview/ Watson Genna, C. (2015) ‘Breastfeeding infants with congenital torticollis’, Journal of Human Lactation, 31(2), pp. 216–220. doi: 10.1177/0890334414568315. Wilke, J., Krause, F., Vogt, L. and Banzer, W. (2016) ‘What is evidence-based about myofascial chains: a systematic review’, Archives of Physical Medicine and Rehabilitation, 97(3), pp. 454–461. doi: 10.1016/j.apmr.2015.07.023.

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 - Disruptive Wound Management (2022) (The above link is from the Association of Tongue-tie Practitioners UK). 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 also trained in the speciality of Orofacial techniques and the YTM tool method for infants which are relatively new concepts 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. 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

The exaggerated latch technique, sometimes called the flipple or flipple nipple technique, is an approach to breastfeeding attachment that aims to help a baby take a deeper, more asymmetrical mouthful of breast tissue. It may be particularly useful for some babies with a high palate, where the shape of the roof of the mouth can influence how the nipple and breast tissue fit within the oral cavity. The technique involves applying gentle pressure near the base of the nipple to angle it upwards towards the baby's forehead, in line with the nose. As the baby opens their mouth and extends their head backwards, they are brought close to the breast, chin first. The pressure is then released as the baby attaches, allowing them to draw the nipple and breast tissue further into the mouth through their own feeding movements and suction (La Leche League GB, 2026). Understanding the anatomy of the palate, the importance of head extension and the mechanics of attachment helps explain why this technique may be useful for some babies with a high palate. Understanding the palate and breastfeeding The palate forms the roof of the mouth and the floor of the nasal cavity. It consists of two anatomically distinct regions: the hard palate at the front, which is supported by bone, and the soft palate towards the back, which contains muscle and movable soft tissue (Standring, 2021). Palates naturally vary in shape, width and height. A high palate has a more pronounced upward arch than a lower, more gently curved palate. This anatomical variation does not automatically indicate a feeding difficulty, but it can influence the space available for the tongue and the relationship between the nipple, breast tissue and other oral structures during feeding. During breastfeeding, the baby draws the nipple and breast tissue further into the mouth as attachment develops. With a deep, asymmetrical latch, the nipple is positioned towards the junction of the hard and soft palates rather than being compressed against the front of the hard palate. La Leche League GB and NHS guidance both describe the importance of a generous mouthful of breast tissue and allowing the baby's head to tip backwards so the nipple can reach further into the mouth (La Leche League GB, 2026; NHS, 2026). Head extension is particularly important because it allows the baby to open their mouth widely and approach the breast at an angle that supports deeper attachment. The chin can make contact with the breast first while the nipple enters the upper part of the mouth (NHS, 2026). For some babies with a high palate, the shape of the oral cavity may influence how the nipple and breast tissue sit within the mouth. Depending on the baby's anatomy and oral function, this may contribute to nipple compression, difficulty maintaining a seal or repeated loss of attachment. These effects are not inevitable, however, and a high palate should be considered alongside the baby's tongue movement, jaw movement, oral coordination and feeding behaviour. For further information about the structures of the mouth and their relationship with feeding, see Infant Oral Anatomy: Structure, Function and Feeding. How the exaggerated latch technique works La Leche League GB describes the flipple as an optional technique for encouraging deeper attachment. Gentle pressure is applied near the base of the nipple to tilt it away from the baby. As the baby opens widely, the breast is brought close so that the nipple enters the mouth last and rolls into position (La Leche League GB, 2026). The direction of the nipple is important, but the technique is not simply about pointing the nipple upwards. The baby's head needs to be free to extend backwards as the mouth opens, allowing the chin to approach the breast first. Head extension, the angle of the nipple and the timing of the caregiver's hand movements work together. The position of the thumb or finger varies according to the feeding position. In many positions, pressure is applied from the upper surface of the breast, viewed from above, with the thumb near the base of the nipple. The nipple is angled upwards towards the baby's forehead, in line with the nose. This should not be interpreted as a fixed instruction to press from underneath the breast; the hand may need to approach from a different direction when the baby's position changes. As the baby opens widely and comes onto the breast, the initial pressure is released. The baby's own mouth movements and suction then help draw the nipple and surrounding breast tissue further into the mouth. Research using ultrasound and measurements of intra-oral vacuum has demonstrated the relationship between tongue movement, vacuum generation and milk flow during breastfeeding (Geddes et al., 2008). The intention of the exaggerated latch technique is for the breast tissue to occupy more of the oral space, including the contour of the palate, while the nipple sits further back rather than remaining compressed towards the front of the hard palate. Once the baby is securely attached and rhythmic swallowing can be seen, the mother can remove her hand from the breast and allow her arm to relax into a more comfortable position, provided the breast and baby remain well supported. Maintaining the same hand position throughout the feed is not the objective; the aim is to facilitate attachment and then allow the baby to feed effectively without unnecessary effort from the mother. The technique builds on the wider principles of deep, asymmetrical attachment described in NHS guidance and breastfeeding support resources. Although the underlying principles of positioning and attachment are established, research specifically evaluating the flipple as a named technique, particularly for babies with a high palate, remains limited. For further explanation of the relationship between body position, head movement and attachment, see Breastfeeding latch and positioning. Why might the flipple help a baby with a high palate? With a high palate, the shape of the roof of the mouth may influence how the nipple and breast tissue fit within the oral cavity. The direction in which the nipple enters the mouth can therefore be particularly relevant. By changing the starting angle of the nipple, the exaggerated latch encourages the baby to take the breast into the mouth with the nipple directed upwards towards the forehead. As the baby extends their head, opens widely and approaches chin-first, the nipple can enter the mouth further back. Releasing the thumb pressure as the baby attaches allows their own suction to draw the breast tissue further into the oral cavity. The intended effect is for the breast tissue to fill more of the space within the mouth, accommodating the contour of the palate while the nipple sits further back. This may help some babies maintain a wider jaw position and reduce compression of the nipple against the hard palate towards the front of the mouth. The potential benefit is therefore not simply that the baby takes a larger mouthful of breast. It is also about the relationship between the nipple, breast tissue, palate and jaw once the baby has attached. This is a proposed mechanical explanation for why the technique may help some babies with a high palate, rather than a clinically established, palate-specific treatment. Its usefulness depends on the individual baby's anatomy, oral movement and ability to sustain effective feeding. The tongue also plays an important role in maintaining the seal around the breast and coordinating sucking and swallowing. Research by Geddes and colleagues (2008) demonstrated that milk flow during breastfeeding coincided with lowering of the posterior tongue and increased intra-oral vacuum. Genna et al. (2021) also explored tongue movement during infant feeding and adult swallowing, examining patterns of tongue kinematics. These studies help explain the complexity of oral movement during feeding, but neither establishes that the flipple improves vacuum or swallowing in babies with a high palate. Where tongue movement is restricted or oral coordination is affected, changing the angle of attachment may not address every contributing factor. Clicking, repeated loss of attachment and nipple compression can have several explanations, so these observations need to be considered within the wider feeding assessment rather than attributed automatically to palate shape. For further reading, see Infant Resting Tongue Posture: Why It Matters and What It Can Tell Us and Why Does My Baby Click When Feeding? Understanding the Causes. How to use the exaggerated latch technique The following steps describe the practical application of the technique. The position of the thumb or finger may need to change according to the feeding position, breast shape and direction from which the baby approaches the breast. 1. Find a comfortable feeding position Choose a position in which you are well supported and your baby can come close to the breast without stretching or twisting. The baby's nose should initially be approximately level with the nipple, allowing space for the head to extend backwards as the mouth opens. Support the baby's shoulders, neck and upper back so that their head can move freely. Avoid pushing the back of the head towards the breast, as this can restrict the extension needed for a wide gape and comfortable attachment (NHS, 2026). The technique can be adapted to different positions, provided the baby can extend their head, approach the breast comfortably and attach effectively. 2. Angle the nipple towards the forehead Place your thumb or finger near the base of the nipple, where the nipple meets the breast, and apply gentle pressure to angle the nipple upwards towards the baby's forehead, in line with their nose. The position of your hand depends on the feeding position. In many cases, the thumb rests on the upper surface of the breast when viewed from above, but another position may require a different hand placement to achieve the same angle. The aim is to change the direction in which the nipple is presented, rather than compressing the nipple or pressing the breast painfully. 3. Allow head extension and wait for a wide gape With your baby positioned nose-to-nipple, allow the nipple to brush the upper lip or the area around the nose. This can encourage the baby to open their mouth in preparation for attachment. As the baby responds, allow their head to tip backwards into extension. This is crucial to the technique. Head extension helps the baby open their mouth widely and changes the angle at which the nipple enters the mouth. Wait for the mouth to open widely enough to take a generous mouthful of breast tissue. The baby should be able to move their head freely rather than having their mouth forced open or their head held in place. 4. Bring the baby to the breast, chin first As the baby opens widely and their head extends backwards, bring them close to the breast so that the chin makes contact first. Keep the nipple angled upwards towards the forehead rather than pointing directly forwards into the centre of the mouth. As the baby attaches, release the thumb or finger pressure. The baby can then draw the nipple and breast tissue further into the mouth through their own feeding movements and suction. The nipple can roll further into the mouth as the baby closes around the breast, allowing more breast tissue to be taken in rather than the baby attaching primarily to the nipple. 5. Check the latch, and look for effective, rhythmical and PAIN FREE swallowing Once the baby is attached, observe how the feeding feels and functions rather than judging the latch by appearance alone. The baby's chin will generally remain close to the breast, with the nose sufficiently clear for comfortable breathing. More of the darker skin around the nipple may be visible above the upper lip than below the lower lip, reflecting an asymmetrical attachment, although the appearance varies with individual anatomy (NHS, 2026). Look for rhythmic sucking and swallowing, and consider whether the mother is comfortable without persistent pinching or sharp pain. Once the baby is securely attached and rhythmic swallowing is visible, the mother can remove her hand from the breast and relax her arm into a more comfortable position, as long as the baby remains supported and attachment is maintained. If the latch remains uncomfortable or the baby repeatedly slips off, gently release the suction before trying again. If the technique does not improve comfort or attachment, the wider feeding picture needs to be considered. For additional guidance on latch mechanics and positioning, see How to Improve Infant Latch: Practical Breastfeeding Support. Other avenues to explore Breastfeeding is multifactorial. Positioning and attachment are important, but the feeding experience is also influenced by the baby's oral function, breast and nipple anatomy, milk flow, breast fullness, the baby's state and development, and the coordination of sucking, swallowing and breathing (NICE, 2021; Watson Genna, 2023). The exaggerated latch may be useful when the angle of attachment appears to be contributing to nipple compression or difficulty maintaining a deep latch. However, persistent pain, repeated loss of attachment or concerns about milk transfer warrant a broader assessment rather than repeated attempts to perfect the same technique. An assessment may consider the baby's tongue movement, jaw movement and ability to maintain a seal around the breast; whether the baby can coordinate sucking and swallowing and sustain effective feeding; the caregiver's breast and nipple anatomy, comfort, milk production and milk flow; and whether the feeding position allows the baby to approach the breast and maintain attachment comfortably. Tongue-tie may be one consideration when restricted tongue movement appears to affect feeding function, but the appearance of the frenulum alone does not establish the cause of feeding difficulties. Equally, not every baby with a high palate has a feeding problem, and not every baby who struggles to attach has a high palate or tongue-tie. An IBCLC or another appropriately qualified healthcare professional with infant feeding expertise can observe a feed and help determine which factors may be contributing. Persistent nipple pain should not simply be accepted as part of breastfeeding; the Academy of Breastfeeding Medicine recommends a careful history and assessment of the feeding dyad when pain continues, rather than assuming that one explanation applies to everyone (Berens et al., 2016). Tongue movement and coordination contribute to the baby's ability to maintain an effective seal, generate intra-oral vacuum and coordinate sucking and swallowing. Where these functions are affected, positioning and attachment techniques may not address every contributing factor. You may find it helpful to read Tongue Function Exercises for Strength, Tone and Motility, which explores exercises to support tongue function, and Tongue-Tie Release Exercises, which discusses exercises following tongue-tie division and the distinction between functional exercises and wound manipulation. You may also find the following articles useful when exploring other possible contributors: Breastfeeding latch and positioning discusses the relationship between positioning, head movement and attachment. Breastfeeding latch support that helps explores persistent nipple pain and the importance of assessing the whole feeding dyad. A guide to understanding your baby's oral function considers oral movement and feeding function without relying on anatomy alone. Infant Skull Shape and Infant Feeding explores how positioning and the wider feeding mechanism may be relevant when an individual baby experiences difficulties. References Berens, P., Eglash, A., Malloy, M. and Stuebe, 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. 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. doi: 10.1016/j.earlhumdev.2007.12.008. Genna, C.W. (ed.) (2023) Supporting Sucking Skills in Breastfeeding Infants. 4th edn. Burlington, MA: Jones & Bartlett Learning. Genna, C., Saperstein, Y., Siegel, S., Laine, A. and Elad, D. (2021) ‘Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns’, Physiological Reports, 9(3), e14685. doi: 10.14814/phy2.14685. La Leche League GB (2026) Positioning & Attachment. Updated May 2026. Available at: https://laleche.org.uk/positioning-attachment/ National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194 NHS (2026) Breastfeeding: positioning and attachment. Page last reviewed 23 June 2026. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/positioning-and-attachment/ Standring, S. (ed.) (2021) Gray's Anatomy: The Anatomical Basis of Clinical Practice. 42nd edn. London: Elsevier.

Choosing a bottle can seem surprisingly complicated. Walk into a shop or search online and you will find bottles described as anti-colic, breast-like, natural, physiological, orthodontic, wide-neck, slow-flow, variable-flow and more. Teats come in different shapes, lengths, widths, materials and flow rates, and some bottles contain valves or several separate components. It can be difficult to work out what actually matters and what is simply clever packaging. There is no single bottle or teat that is right for every baby. The NHS also states that there is no evidence that one type of bottle or teat is better than another, and suggests that simple bottles which are easy to wash and sterilise are probably best (NHS, 2026a). At the same time, research does show that the characteristics of a bottle and teat can influence how milk flows and how a baby sucks, swallows and breathes. The important distinction is that this does not mean one particular brand or design is universally better. Your baby's mouth, palate, oral movements, sucking skills, milk flow, feeding position and overall coordination all contribute to how a particular teat works for them. Teat shape matters Teats are not all shaped in the same way. Some are relatively short and flat, some are rounded, some are long and narrow, and others have a broad base which gradually tapers towards the end. The shape changes the way the teat sits inside the baby's mouth and the way the lips, tongue and jaw can interact with it. Bottle feeding is not simply a matter of milk dripping through a hole. Babies use a combination of suction and compression to remove milk, and the characteristics of the teat can influence how that happens (Kotowski et al., 2020). A short, relatively flat teat may encourage more compression of the teat between the tongue and palate or gums. A broader, gradually tapered teat provides a different structure for the mouth to work around. This does not mean that one shape will automatically produce a better feed, or that a particular teat will suit every baby. I generally favour a broad, gradually tapered or sloping teat, particularly when a family is combination feeding. There is some research suggesting that teat design can influence oral movements and sucking patterns. For example, Segami et al. (2013) studied an experimental teat with a wide base and firm shaft and found similarities in some perioral movements and sucking patterns when compared with breastfeeding. However, this was a small study involving an experimental teat, so it cannot be used to conclude that every broad teat is more physiological or better for breastfeeding. This distinction is important because bottle manufacturers increasingly use terms such as "breast-like" or "designed to mimic breastfeeding". A 2025 study of bottles marketed in the UK found that claims about mimicking breastfeeding physiology, supporting combination feeding, reducing bottle refusal or preventing nipple confusion were common, but the scientific evidence underpinning those marketing claims was scarce and often inadequate (Maxwell, Self and Bould, 2025). A broad, gradually tapered teat may therefore be a practical choice for some babies, particularly alongside responsive or paced bottle feeding, but it cannot guarantee that a baby will continue to move comfortably between breast and bottle. It is also worth remembering that compression and suction are not the same thing. Babies can use both during bottle feeding, and the balance between them can vary according to the teat, flow and the individual baby's oral movements. A baby using more compression is not necessarily "doing it wrong", but if the feeding pattern is inefficient, tiring or uncomfortable, it is worth looking at the whole feeding picture rather than simply changing the bottle. You don't have to stay loyal to one teat brand Babies change as they grow, and the teat that works well at one stage may not always be the one that works best later on. Their mouth grows, their oral skills develop, their sucking becomes more coordinated and their feeding needs can change. A teat that was comfortable and effective when a baby was younger may eventually feel too slow, too fast, too short or simply different from what they now manage comfortably. This is one reason I would be cautious about becoming too attached to a particular brand or assuming that moving up within the same range is always the answer. Different manufacturers use different shapes, materials, flow rates and age recommendations, so a "next stage" teat from one brand may behave quite differently from another brand's equivalent. Watching how your baby is actually feeding is more useful than relying on the number or age printed on the packet. The same applies if you are combination feeding. A teat that worked alongside breastfeeding in the early weeks may not necessarily remain the best option as your baby's feeding skills develop. Equally, changing a teat is not something that needs to happen simply because a manufacturer suggests a particular age. If your baby is feeding comfortably, maintaining a good suck-swallow-breathe pattern and managing the flow without difficulty, there may be no reason to change it simply because the packaging says they have reached the next stage. Sometimes, however, a change can be helpful. Your baby's developing oral anatomy, palate shape, sucking skills, milk flow needs or overall feeding pattern may all influence which teat works comfortably for them. This is where looking at the whole feeding picture becomes more useful than choosing a teat based on brand loyalty alone. Your baby's palate can make a difference The roof of the mouth provides part of the surface against which the tongue works during feeding, so palate shape can influence how a teat sits and how the tongue and jaw interact with it. A high or narrow palate does not automatically mean that a baby will struggle with bottle feeding, and there is no single teat designed for every baby with a particular palate shape. However, if a teat repeatedly slips, is difficult for the baby to maintain in the mouth, or feeding involves considerable compression, dribbling or fatigue, the shape and dimensions of the teat may be worth considering alongside other aspects of the feed. There is some evidence that oral cavity dimensions and teat dimensions are relevant to sucking performance, although much of the research is older and does not provide a simple prescription for which teat should be used (Hummel and Herrmann, 1989). A case report has also described a newborn with a high arched palate whose feeding improved when a larger-hole teat was used, although a single case cannot be used to establish a general recommendation (Eren, Bilgin and Kara, 2015). This is a good example of why a teat should not be selected solely because it is marketed for a particular oral shape. The individual baby's response matters more than the label. Premature babies may have different needs Premature and very-low-birth-weight babies may have different feeding requirements because their sucking, swallowing and breathing coordination is still developing. Teat choice can therefore become part of a more individualised feeding assessment. Research in very-low-birth-weight infants has shown that different bottle nipples can affect sucking and milk transfer (da Costa, van den Engel-Hoek and Bos, 2008). This does not mean that there is one particular "premature baby teat" that is best for every baby. The appropriate equipment may depend on gestational age, oral size, feeding maturity, respiratory status and the baby's ability to manage the flow. For a premature baby, particularly one who is still developing coordinated oral feeding, bottle and teat selection is best considered alongside the wider feeding assessment rather than by age or packaging alone. Teat flow is not standardised One of the most confusing things about bottle feeding is that a "slow", "medium" or "fast" teat does not have a universal meaning. Manufacturers use their own terminology and their own testing methods. A slow-flow teat from one company can therefore behave very differently from a slow-flow teat from another. This has been demonstrated in research. Pados, Park and Dodrill (2019) measured 375 individual nipples representing 25 different types and found milk flow rates ranging from 0.86 to 37.61 mL per minute. The information printed on the packaging did not accurately reflect the measured flow rates. The physical characteristics of the teat also matter. Material, shape, hole size, rigidity and compressibility can all affect milk flow, alongside how much pressure the individual baby generates (Kotowski et al., 2020). This is why the age printed on a packet should not be treated as a developmental requirement. It is manufacturer guidance. The NHS similarly advises that as babies become used to bottle feeding and grow, changes in flow can be considered, but this should be led by the baby rather than a rigid age rule (NHS, 2026b). Faster is not necessarily better It can be tempting to think that a baby who is getting older should automatically move to a faster teat. Sometimes a faster flow is appropriate, but faster is not inherently better. A flow that is too fast for an individual baby can make it harder to coordinate sucking, swallowing and breathing. You might notice coughing, spluttering, gulping, milk leaking from the mouth, pulling away from the bottle or becoming unsettled during the feed. A flow that is too slow can also be difficult. Some babies may suck for a very long time, become tired or frustrated, or fall asleep before taking enough milk. Research has demonstrated that babies can adapt their sucking patterns to different teat flows. Lagarde et al. (2019), for example, found differences in swallow rate and suck-to-swallow ratios when healthy infants used teats with different flow characteristics. The study was small, involving 16 term-born infants aged two to five months, and one of the teats had a higher measured flow than the other. The aim is therefore not to find the fastest flow a baby can tolerate. It is to find a flow that allows that particular baby to feed comfortably and coordinate their sucking, swallowing and breathing. What about variable-flow teats? Variable-flow or vari-flow teats allow the milk flow to change according to how the teat is positioned or how the baby sucks. They can be useful in some circumstances, but I am cautious about them for babies who already have difficulty with oral-motor coordination. For a baby who has tongue restriction or other difficulty coordinating their sucking pattern, a flow that changes according to pressure or positioning can sometimes make the feeding experience less predictable. That does not mean that variable-flow teats are unsuitable for every baby with a tongue-tie, but they are not a choice I would make automatically. If a baby is already struggling to control milk flow, it can be useful to simplify the variables and consider whether a consistent, predictable flow would make feeding easier to assess. What does the valve actually do? Many bottles contain a valve or venting system. The basic mechanical purpose is quite simple: as milk leaves the bottle, air needs to enter the bottle to replace the lost volume. Without adequate venting, a vacuum can develop and the teat may flatten or collapse. A valve can allow air to enter the bottle and help regulate the pressure inside it. Different bottle designs achieve this in different ways, and some have additional components intended to keep air away from the milk pathway. The term "anti-colic" is much broader than the mechanical function of the valve, though. A valve can change airflow through the bottle; it cannot guarantee that a baby will not have colic, wind or unsettled behaviour. Colic and digestive discomfort have many possible causes, and a bottle described as "anti-colic" should therefore be understood as a description of the bottle's design rather than a promise about what your baby will experience. The material a teat is made from Most modern bottle teats are made from silicone or rubber. These materials do not behave in exactly the same way. Silicone is a synthetic material. It is generally clear, relatively firm and does not contain natural rubber latex. Natural rubber, on the other hand, is derived from natural rubber latex and tends to be softer and more flexible. Natural rubber products can also change more noticeably with repeated use and sterilisation. For most families, the choice may simply come down to how the teat feels, how the baby responds to it, how durable it is and how well it fits the bottle system. Latex sensitivity is another consideration. If a baby or caregiver has a known natural rubber latex allergy or sensitivity, the material needs to be checked carefully rather than assuming that all soft or rubber-like teats are silicone. Whichever material you choose, inspect the teat regularly. Teats can become damaged, split, sticky or otherwise deteriorate with use and sterilisation. NHS guidance specifically recommends checking bottles and teats for damage and replacing damaged equipment (NHS, 2026a; NHS, 2026c). Glass, plastic or collapsible bottles? The bottle itself can be made from several materials, with glass and plastic being the most common choices. Glass bottles are durable and can be straightforward to clean, although they are heavier and can break if dropped. Plastic bottles are lighter and easier to carry, which can be useful for everyday life, but they can become scratched or worn over time and should still be checked regularly. Some bottles are soft or collapsible. These can be particularly useful in specialist feeding situations, but a soft bottle is not simply another bottle to squeeze whenever a baby seems to need more milk. Some specialist systems require the caregiver to use the bottle in a very specific way. This is particularly important for babies with a cleft palate, where specialist bottles may use squeezing or valves to help provide milk. These systems should only be used following guidance from the baby's cleft feeding team. For everyday bottle feeding, there is no requirement to buy an expensive bottle. NHS guidance states that simple bottles which are easy to wash and sterilise are probably best (NHS, 2026a). What about anti-colic and self-sterilising bottles? Anti-colic bottles often combine a valve or venting system with a particular bottle and teat design. The mechanical features can be useful, but the name "anti-colic" should not be interpreted as a guarantee that a baby will not experience wind or colic. A self-sterilising bottle is designed so that the bottle components can be assembled in a particular way and sterilised, usually using steam in a microwave according to the manufacturer's instructions. This can be convenient, but it does not remove the need to clean the bottle properly before sterilisation. Sterilisation and cleaning are separate steps. Milk residue needs to be removed before the sterilisation process. If you are considering a bottle with several valves, membranes and separate components, it is also worth thinking about whether you will be able to clean every part thoroughly and consistently. A theoretically sophisticated bottle is not particularly useful if it becomes difficult to clean properly. Sterilising still matters Whatever bottle or teat you choose, hygiene remains important. NHS guidance recommends sterilising bottles, teats and other feeding equipment until your baby is at least 12 months old. Equipment should be cleaned in hot, soapy water as soon as possible after feeds and rinsed in clean, cold running water before sterilisation (NHS, 2026c). There are several recognised methods, including cold-water sterilising solution, steam sterilising and boiling. If boiling is used, NHS guidance recommends boiling the equipment for at least 10 minutes and checking that the equipment is safe to boil. Teats can become damaged more quickly with boiling, so they should be inspected regularly (NHS, 2026c). Steam sterilisers and self-sterilising bottles should be used according to the manufacturer's instructions. Cold-water sterilising solutions also need to be prepared and changed according to the instructions. The important part is not which sterilising method looks most impressive. It is that the method is suitable for the equipment and used consistently. Babies with cleft palate need specialist advice Babies born with a cleft lip and/or palate can have very different feeding requirements because the opening in the palate can make it difficult to create the seal and vacuum normally used for feeding. Specialist bottles and teats are available for babies born with a cleft. CLAPA supplies specialist feeding equipment used and recommended by NHS Cleft Nurse Specialists, and advises families to speak with their Cleft Nurse Specialist about which equipment is appropriate (CLAPA, 2026a; CLAPA, 2026b). Some specialist systems work by squeezing a soft bottle while the baby sucks, while others use valves or specially designed teats. These systems need to be demonstrated and used according to the advice of the baby's cleft team. This is not an area where I would recommend buying a specialist bottle based simply on an online description. The baby's cleft anatomy, feeding ability and the equipment available through their specialist service all need to be considered together. What if your baby refuses the teat? Bottle refusal can be surprisingly complicated. Sometimes the issue is the teat itself, but sometimes it is the flow, feeding position, temperature of the milk, the person offering the bottle, the baby's previous feeding experiences or simply the fact that the baby is not interested in drinking at that particular moment. A baby who has previously breastfed may also respond differently to a bottle from a baby who has always bottle fed. If you are trying different approaches, it can be helpful to change one variable at a time. Changing the bottle, teat, flow, feeding position, caregiver and routine all at once makes it very difficult to work out what your baby is responding to. Repeatedly persuading or forcing a baby to take a bottle can also turn feeding into a stressful experience. Watching your baby's communication and allowing pauses is part of responsive bottle feeding. I have written more about this in When Your Baby Suddenly Refuses the Bottle. If bottle feeding continues to be difficult, it is worth considering the feeding itself rather than simply buying another bottle. Teat shape and flow, oral coordination, positioning, respiratory factors and other aspects of feeding can all contribute. Bottle-feeding difficulties do not automatically mean that a baby has a tongue-tie, and a tongue-tie does not automatically explain every bottle-feeding difficulty. A bottle is not always necessary There are circumstances where a baby needs to receive expressed breast milk, donor milk where appropriate or infant formula but does not need to use a bottle. Depending on their age, development, health and feeding ability, an alternative feeding method may sometimes be considered. This might include cup feeding or another method recommended by an appropriately trained healthcare professional. For an older breastfed baby who can sit independently and is developmentally ready for a cup, there may not be a need to introduce a bottle simply because they need another way of receiving milk. Going directly to a cup can sometimes be a practical option. I have written more about the different possibilities in Alternative Feeding Methods for Babies. The appropriate method depends on the individual baby. Alternative feeding methods should not be selected simply because a particular method is described online as being "better", and some methods need to be demonstrated face to face because the safety of the method depends on the baby's ability to coordinate sucking, swallowing and breathing. If you are using a bottle alongside breastfeeding Combination feeding can work in many different ways. Some babies have one or two bottles a day and breastfeed for the remaining feeds. Others have expressed milk or formula at different times of the day, or alternate between breast and bottle according to what works for their family. If maintaining breastfeeding is important to you, the way the bottle is offered may be worth considering alongside the bottle and teat themselves. Paced bottle feeding can give your baby more opportunity to control the speed of the feed, take pauses and communicate when they have had enough. Holding the bottle relatively horizontally rather than allowing milk to pour continuously into the mouth is one part of this approach. I have written more about this in How to Pace Bottle Feeds: A Calm Practical Guide. Position can also make a difference. Some babies are more comfortable in one bottle-feeding position than another, particularly when they are managing a faster flow or are still developing their suck-swallow-breathe coordination. You can read more in Bottle Feeding Positions. A broad, gradually tapered teat combined with responsive or paced feeding may be a useful practical approach for some babies moving between breast and bottle. What it cannot do is guarantee that a baby will avoid teat preference, continue breastfeeding or experience exactly the same mechanics as breastfeeding. The 2025 UK research into bottles marketed as "breast-like" is particularly useful here. It found that manufacturers commonly make claims about supporting combination feeding, reducing bottle refusal, preventing nipple confusion and reproducing breastfeeding physiology, but found very little high-quality scientific evidence to support these claims (Maxwell, Self and Bould, 2025). That does not mean that families should avoid trying different teats. It simply means that the choice is better viewed as an individual feeding decision than as a guarantee attached to a particular brand. There is no perfect bottle The most expensive bottle is not necessarily the most suitable bottle, and a bottle described as "natural", "physiological" or "breast-like" is not automatically going to work better for your baby. At the same time, it is reasonable to pay attention to the shape, flexibility, material and flow of the teat because these characteristics really can affect the mechanics of bottle feeding. Research shows that babies can adapt to different teat characteristics, but that does not mean every baby will respond to every teat in the same way (Lagarde et al., 2019; Kotowski et al., 2020). For one baby, a broad tapered teat may feel comfortable. Another may manage a different shape more effectively. One baby may need a slower flow for several months, while another may become frustrated by the same flow. A baby who feeds comfortably from a particular teat at three months may respond differently as their mouth and feeding skills develop. The useful question is therefore not simply "Which bottle is the best?" It is "How is my baby managing this bottle and teat?" Are they able to maintain a comfortable seal? Are they able to coordinate sucking, swallowing and breathing? Is the flow manageable? Are feeds comfortable rather than exhausting? Are they able to pause and communicate when they need a break? Are they taking enough milk for their individual needs? Those questions tell you much more about whether a bottle is working than the name printed on the packet. References CLAPA (2026a) About CLAPA's services for the UK cleft community. Cleft Lip and Palate Association. Available at: https://clapa.com/about-clapa/what-we-do/ CLAPA (2026b) Feeding babies born with a cleft. Cleft Lip and Palate Association. Available at: https://clapa.com/support-and-community/for-parents-and-families/feeding-babies-born-with-a-cleft/ da Costa, S.P., van den Engel-Hoek, L. and Bos, A.F. (2008) 'Sucking and swallowing in infants with very low birth weight: the effect of different bottle nipples', Acta Paediatrica, 97(4), pp. 473–476. doi:10.1111/j.1651-2227.2008.00704.x. Available at: https://pubmed.ncbi.nlm.nih.gov/18393901/ Eren, M., Bilgin, S. and Kara, B. (2015) 'Feeding an infant with high arched palate by high flow rate bottle nipple', Asia Pacific Journal of Clinical Nutrition, 24(4), pp. 756–758. doi:10.6133/apjcn.2015.24.4.16. Available at: https://pubmed.ncbi.nlm.nih.gov/26693762/ Hummel, P. and Herrmann, W. (1989) 'Physiologic sucking performance and the shape of the oral cavity in infants and young children with respect to the design of nipples for nursing bottles and pacifiers', Fortschritte der Kieferorthopädie, 50(5), pp. 384–391. doi:10.1007/BF02171173. Available at: https://pubmed.ncbi.nlm.nih.gov/2583621/ Kotowski, J., Fowler, C., Hourigan, C. and Orr, F. (2020) 'Bottle-feeding an infant feeding modality: An integrative literature review', Maternal & Child Nutrition, 16(2), e12939. doi:10.1111/mcn.12939. Available at: https://pubmed.ncbi.nlm.nih.gov/31908144/ Lagarde, M.L.J., van Alfen, N., de Groot, S.A.F., Geurts, A.C.H. and van den Engel-Hoek, L. (2019) 'Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study', BMC Pediatrics, 19, 477. doi:10.1186/s12887-019-1859-y. Available at: https://pubmed.ncbi.nlm.nih.gov/31805974/ Maxwell, C., Self, B. and Bould, K. (2025) 'A descriptive investigation of infant feeding bottles marketed in the UK designed to replicate breastfeeding and the evidence that underpins them', Maternal & Child Nutrition, 21(3), e70008. doi:10.1111/mcn.70008. Available at: https://pubmed.ncbi.nlm.nih.gov/40023778/ NHS (2026a) Bottle feeding advice. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/advice/ NHS (2026b) What you need for formula feeding. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/how-to-make-up-a-feed/things-you-need-for-formula-feeding/ NHS (2026c) Sterilising baby bottles. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/sterilising-baby-bottles/ Pados, B.F., Park, J. and Dodrill, P. (2019) 'Know the flow: Milk flow rates from bottle nipples used in the hospital and after discharge', Advances in Neonatal Care, 19(1), pp. 32–41. doi:10.1097/ANC.0000000000000538. Available at: https://pubmed.ncbi.nlm.nih.gov/30028734/ Segami, Y., Mizuno, K., Taki, M. and Itabashi, K. (2013) 'Perioral movements and sucking pattern during bottle feeding with a novel, experimental teat are similar to breastfeeding', Journal of Perinatology, 33, pp. 319–323. doi:10.1038/jp.2012.113. Available at: https://pubmed.ncbi.nlm.nih.gov/22975983/

There is more than one way to hold a baby for a bottle feed. The traditional semi-upright, cradle-like position is familiar to many families and is often the position shown in general bottle-feeding guidance. However, it is not the only option. Some babies seem more comfortable in a different position, particularly if they are finding the flow of milk difficult to manage, are still developing their suck-swallow-breathe coordination, or are moving between breast and bottle. The position you choose can affect how your baby is supported, how easily you can see their face and respond to their feeding cues, and how the milk reaches their mouth. There is no single bottle-feeding position that is right for every baby, and exploring different positions can sometimes make feeding more comfortable for both of you. What can be in a bottle? A bottle may contain expressed breast milk, infant formula, or a combination of both. For babies under 6 months, milk feeds provide both nutrition and hydration. Correctly prepared formula already contains water as part of the feed, so water should not be added to or used to dilute formula. Expressed breast milk is still breast milk, but feeding expressed milk from a bottle is not necessarily identical to feeding directly at the breast. Human milk naturally varies in composition, including its fat content. Research has also found that the way milk is expressed can affect the composition of the milk obtained. A systematic review found that expression technique affected fat content, although the available studies were limited and did not demonstrate the same effect on protein or lactose content (Çınar and Karakaya Suzan, 2021). This means expressed breast milk should not simply be assumed to have exactly the same composition as the milk an infant receives during direct breastfeeding. There is no single fixed composition of "breast milk", because human milk naturally varies and the milk obtained can also be influenced by how and when it is expressed. What makes a comfortable bottle-feeding position? A useful bottle-feeding position is one in which your baby is well supported but still has enough freedom to move their head, mouth and body. Being able to see your baby's face is particularly important because their facial expression, breathing, movements and feeding cues can all tell you something about how the feed is going. The NHS recommends holding a baby in a semi-upright position for bottle feeds, with their head supported so they can breathe and swallow comfortably (NHS, 2023). The NHS also recommends watching the baby and responding to cues that they need a break rather than expecting them to continue until the bottle is empty (NHS, 2023). Beyond these general principles, there are several positions that can be explored. The traditional semi-upright position The traditional semi-upright position is probably the one most people picture when they think about bottle feeding. Your baby is held close to your body, supported along your arm, with their head higher than their bottom and their head and neck comfortably supported. For some babies, this is a very comfortable and familiar way to feed. It can also make it easy for the caregiver to maintain eye contact, notice feeding cues and enjoy the closeness of the feed. However, the position itself does not determine how quickly milk reaches your baby. If milk is flowing continuously or too quickly, a baby may have fewer opportunities to pause and regulate the feed themselves. This is one reason that positioning needs to be considered alongside the bottle, teat, milk flow and the way the feed is offered. The NHS advises against forcing a baby to finish a bottle because this can result in overfeeding (NHS, 2023). Upright on your lap, facing outwards Some babies seem to prefer being held more upright, particularly when they are alert and interested in their surroundings. One option is to sit your baby supported on your lap, facing outwards, while keeping them close and providing whatever support they need around their body, head and neck. This can provide a very different experience from being cradled across the caregiver's body. It may give a baby who dislikes feeling enclosed a little more freedom to look around, while still allowing the caregiver to remain close and responsive. The important consideration is whether you can still see your baby's face and observe how they are managing the feed. If the position means that the caregiver cannot see the baby's face, another responsible adult should be able to observe the baby throughout the feed. Elevated side-lying Elevated side-lying is another position that has received particular attention in research involving premature babies and infants with developing feeding skills. In this position, the baby is supported on their side with their body well aligned and their head slightly elevated. The caregiver remains close and can see the baby's face throughout the feed. Research in preterm infants has explored semi-elevated and elevated side-lying positions in relation to feeding performance and physiological stability (Clark et al., 2007; Park et al., 2014; Girgin, Gözen and Karatekin, 2018; Raczyńska and Gulczyńska, 2019). Feed Eat Speak has also described elevated side-lying as an option that may be explored with newborns and babies experiencing feeding difficulties (Zimmels, 2018). Although much of the research relates specifically to premature infants, the position can also be considered as one of several options for a term baby who is finding a conventional bottle-feeding position difficult. A familiar breastfeeding-style position For a baby who normally breastfeeds, the transition to a bottle can involve more than simply introducing a different container. The position of the baby's body and the closeness of the caregiver may also feel different. Some families therefore find it helpful to experiment with a position that has elements of the baby's familiar breastfeeding position. This might be a cross-cradle-style position, with the baby's body supported across the caregiver, or a side-by-side or under-arm position in which the baby is supported alongside the caregiver's body. The purpose of the latter is not literally to put the baby "in the armpit". Rather, it is a way of using a familiar body position that may feel more recognisable to a baby who is accustomed to feeding at the breast. There is no guarantee that a familiar position will make a baby accept a bottle, but it can be one of several things worth trying when the change from breast to bottle is proving difficult. Positions for premature or smaller babies Premature and smaller babies may need more individualised support because their ability to coordinate sucking, swallowing and breathing can still be developing. The research into elevated and semi-elevated side-lying has particularly focused on preterm infants, with studies examining how different positions affect feeding performance and physiological responses (Clark et al., 2007; Park et al., 2014). For a premature baby, a baby with complex medical needs or an infant experiencing significant feeding difficulties, positioning may need to be tailored with support from the neonatal or infant-feeding team. A position that is useful for one baby is not automatically appropriate for another. What about the bottle and teat? Position is only one part of bottle feeding. The bottle itself, the shape and flexibility of the teat and the rate at which milk flows can all influence how a baby experiences a feed. It is very common for families to recommend products to one another, but a bottle or teat that works beautifully for one baby may be much less suitable for another. Babies have different oral dimensions, palate shapes and suck-swallow-breathe coordination, so there is no reason to expect one particular teat shape or bottle system to suit every baby. Marketing can also make particular products sound as though they have universal advantages. It is worth being cautious about this, particularly when a product is presented as the answer to a feeding problem without considering the individual baby. If you want to explore the different features of bottle teats in more detail, see Bottle Teat Shapes. Position is not the same as paced bottle feeding Positioning and pacing are closely related, but they describe different things. Positioning is about how your baby's body is supported while they feed. Pacing is about how the flow of milk is offered and how your baby is given opportunities to pause. A baby can therefore be held in a comfortable position and still find the milk flow too fast. Equally, changing the position alone will not necessarily resolve a feeding difficulty. For a more detailed explanation of pacing, see How to Pace Bottle Feeds: A Calm Practical Guide. When a baby refuses a bottle: movement and sensory changes For some babies, changing the whole environment around the feed can be worth exploring. Rather than sitting still and offering the bottle in the same position repeatedly, some families find that their baby is more willing to accept a bottle while being held upright and gently walked or swayed. This is sometimes described as motion feeding. The movement may provide a familiar sensory experience and can be particularly worth considering when a baby becomes upset as soon as they are settled into a conventional bottle-feeding position. Gentle movement, rather than vigorous bouncing or rocking, can sometimes help a baby settle enough to explore the bottle. A change in the sensory environment may also be helpful. Some babies respond to a calm voice, singing, a familiar lullaby or gentle background sound such as white noise while they are being offered a bottle. These approaches are quite different from using a screen to distract an infant, and screens are not necessary for this purpose. The aim should not be to distract a baby so thoroughly that they take the bottle without noticing what they are doing. Instead, a calm change in movement, sound or surroundings may help some babies feel more settled and receptive to trying something unfamiliar. If a baby consistently refuses a bottle, it is worth considering why rather than repeatedly trying to persuade them to drink. The feeding position, teat shape and flow, temperature of the milk, the person offering the bottle and whether the baby is accustomed to breastfeeding can all be relevant. Bottle propping: this is dangerous Bottle propping is sometimes presented as a convenient way to allow a baby to feed without the caregiver having to hold the bottle. It may involve balancing the bottle against a blanket, cushion or toy, using a specially designed holder, or buying a product intended to keep the bottle in the baby's mouth. This is not a safe way to bottle feed. A baby who is feeding from a propped bottle cannot reliably control what happens if the flow becomes too much for them. They may cough, choke, aspirate milk or become unable to breathe properly, while the adult may not recognise what is happening quickly enough to intervene. The danger is serious enough that the UK Office for Product Safety and Standards has issued safety alerts about baby self-feeding products and prop feeders. These products are designed to allow a baby to bottle feed with little or no assistance from a caregiver and have been identified as presenting a risk of serious harm or death from choking or aspiration pneumonia (OPSS, 2022; OPSS, 2025). Some of these products have been removed from the UK market, yet similar products and "hands-free" feeding gimmicks can still appear online. The fact that something is being sold or marketed specifically for babies does not mean that it has been shown to be safe. The NHS is equally clear that babies should never be left alone with a propped-up bottle because of the risk of choking (NHS, 2023). This is therefore much more than a question of whether bottle propping is "good practice". A baby should never be left to feed from a propped bottle or a self-feeding device. The potential consequences can be fatal. Is there a best bottle-feeding position? There is no single position that every baby needs to use. The traditional semi-upright position may work very well for one baby, while another may settle more comfortably in an elevated side-lying, upright or breastfeeding-style position. A baby's preferred position may also change as they grow and their feeding skills develop. Rather than looking for one "best" position, it can be more helpful to consider how your individual baby is managing the feed. Are they comfortable? Can you see their face? Are they able to breathe and swallow comfortably? Can you recognise when they need a pause? Does the position allow you to respond to their cues? If a baby is regularly coughing, choking, spluttering, losing milk from their mouth, becoming distressed, taking a very long time to feed or struggling to coordinate feeding and breathing, changing position may be worth exploring, but persistent feeding difficulties deserve individual assessment rather than simply trying different positions indefinitely. References Clark, L., Kennedy, G., Pring, T. and Hird, M. (2007) ‘Improving bottle feeding in preterm infants: investigating the elevated side-lying position’, Infant, 3(4), pp. 154–158. Çınar, N. and Karakaya Suzan, Ö. (2021) ‘Investigation of the effect of human milk expression techniques on milk content: a systematic review’, Journal of Tropical Pediatrics, 67(6), fmab108. Girgin, B.A., Gözen, D. and Karatekin, G. (2018) ‘Effects of two different feeding positions on physiological characteristics and feeding performance of preterm infants: a randomized controlled trial’, Journal for Specialists in Pediatric Nursing, 23(2), e12214. NHS (2023) ‘Bottle feeding advice’. NHS. NHS (2023) ‘Bottle feeding your baby’. NHS Best Start in Life. Office for Product Safety and Standards (OPSS) (2022) ‘Product Safety Alert: Baby Self-Feeding Pillows / Prop Feeders (PSA3)’. GOV.UK. Office for Product Safety and Standards (OPSS) (2022) ‘Product Safety Alert: Baby Self-Feeding Products (PSA4)’. GOV.UK. Office for Product Safety and Standards (OPSS) (2025) ‘Warning of new variant of dangerous baby self-feeding products’. GOV.UK. Park, J., Thoyre, S., Knafl, G.J., Hodges, E.A. and Nix, W.B. (2014) ‘Efficacy of semielevated side-lying positioning during bottle-feeding of very preterm infants’, Journal of Perinatal & Neonatal Nursing, 28(1), pp. 69–79. Raczyńska, A. and Gulczyńska, E. (2019) ‘The impact of positioning on bottle-feeding in preterm infants (≤34 GA): a comparative study of the semi-elevated and the side-lying position – a pilot study’, Developmental Period Medicine, 23(2), pp. 117–124. Zimmels, S. (2018) ‘Elevated side lying bottle feeding’, Feed Eat Speak, 14 August.

Breast milk is much more than a source of food. It is a complex, biologically active fluid containing water, fats, carbohydrates, proteins, vitamins, minerals and a range of components involved in immune protection, digestion and development. Its composition changes during the early days after birth, throughout individual feeds and across the entire period of lactation (Ballard and Morrow, 2013). These changes are a normal part of lactation. Colostrum, produced in the first days after birth, differs from mature milk in its composition and concentration of many components. As lactation progresses, breast milk continues to provide energy and nutrients alongside antibodies, enzymes, hormones and other biologically active substances. Its composition also varies between individuals and according to the stage of lactation (Ballard and Morrow, 2013; Dror and Allen, 2018). The main components of breast milk Water Breast milk is approximately 87% water, making it an important source of hydration as well as nutrition. For a healthy baby who is exclusively breastfed, breast milk provides the fluid needed during the first six months of life, including in warm weather. Additional water is not routinely required during this period (WHO, 2023). Carbohydrates Lactose is the principal carbohydrate in breast milk. It provides energy and contributes to the absorption of certain minerals. Breast milk also contains human milk oligosaccharides (HMOs), a diverse group of complex carbohydrates that are not primarily digested by the infant. Instead, many HMOs help shape the developing gut microbiome and can act as decoy receptors for certain pathogens, contributing to the protection of the infant's intestinal environment (Bode, 2012). The composition of HMOs varies between individuals, partly because of genetic differences. This is one example of how breast milk contains components that do more than provide calories. Fats Fat is an important source of energy for a growing infant and contributes to the development of the brain, nervous system and other tissues. Breast milk contains a range of fatty acids, including essential fatty acids that the body cannot produce in sufficient quantities on its own. Fat concentration varies between individuals, between feeds and as milk is removed from the breast. It is influenced by factors including how full the breast is and the stage of milk removal. This natural variation is one reason that breast milk should not be thought of as having a single, fixed nutritional composition (Ballard and Morrow, 2013; Kent et al., 2006). Proteins Breast milk contains proteins that provide amino acids for growth and development, as well as proteins with other functions. These include whey and casein proteins, enzymes and immune-related proteins such as lactoferrin. Lactoferrin binds iron and has antimicrobial properties, while other proteins help with digestion, nutrient transport and immune function. The relative proportions of proteins change over the course of lactation, with colostrum having a different profile from mature milk (Ballard and Morrow, 2013). Vitamins and minerals Breast milk contains vitamins and minerals required for growth and development. The concentrations of some nutrients are influenced by maternal nutritional status, while others are more tightly regulated by the body. Breast milk is not identical in composition for every lactating person, and some nutrients, including vitamin D, may require particular consideration under UK guidance. Vitamin supplementation should be considered in line with current NHS advice and the individual circumstances of the infant and lactating person, rather than assuming that breast milk always provides every nutrient in the same quantity (NHS, n.d.). Antibodies and other immune components Breast milk contains antibodies, immune cells and other components that contribute to immune protection. Secretory immunoglobulin A (sIgA) is a particularly important antibody in human milk. It helps protect the surfaces of the infant's mouth, gut and respiratory tract by binding to microbes and supporting mucosal defence. Breast milk also contains immune cells, cytokines, enzymes and other substances involved in the regulation of immune responses. These components are part of a wider biological system that supports the infant while their own immune system continues to develop (Ballard and Morrow, 2013; Verhasselt et al., 2024). Enzymes, hormones and growth factors Breast milk contains enzymes that assist with digestion and other biological processes, alongside hormones and growth factors involved in metabolism, intestinal development and physiological regulation. Their presence illustrates that breast milk is not simply a mixture of nutrients; it is a biologically active fluid that interacts with the developing infant in several ways (Ballard and Morrow, 2013; Cacho and Lawrence, 2017). How breast milk is made Breast milk is produced in specialised cells within structures called alveoli in the breast. These cells take up substances from the maternal circulation and use them to synthesise milk components. Breast milk is therefore made using materials supplied through the blood, but it is not simply blood that has been filtered into milk. The mammary gland actively produces and transports the different components of milk (Ballard and Morrow, 2013). Two hormones play important roles in lactation. Prolactin supports milk synthesis, while oxytocin causes the small muscle-like cells surrounding the alveoli to contract, moving milk towards the ducts and nipple. This movement is known as the milk ejection reflex, often called let-down. Milk ejection can occur more than once during a feed, and its timing and strength vary between individuals and circumstances (Neville, 2001). Milk production is also influenced by milk removal. As milk is regularly removed, the breast receives signals that support continued production. When milk remains in the breast for longer periods, production generally slows. This is one reason that effective milk removal and the frequency of feeding or expressing can influence milk supply (Kent et al., 2006). The Association of Breastfeeding Mothers (2023) explains the process in its illustrated and animated video, How Breastmilk Is Made, illustrated and animated by JoJo Ford. How a baby's saliva may relate to breast milk The relationship between a baby's mouth and breast milk is an area of interest because lactation involves interaction between the infant and the lactating person's immune system. Breast milk contains antibodies and other immune components, and maternal immune responses can influence the antibodies present in milk. These responses are part of the body's wider immune activity, including responses to microbes encountered by the mother (Verhasselt et al., 2024). It is sometimes explained that a baby's saliva is absorbed through the nipple or areola and directly signals the mother's body to produce specific antibodies for that baby. Although communication between the infant and the lactating person's immune system is biologically plausible and an area of ongoing research, this precise pathway should not be presented as an established mechanism. The extent to which infant saliva directly changes the specific antibody content of breast milk, and how this might occur, is not yet fully understood. What is established is that breast milk contains immune components that support the infant's mucosal defences, and that its composition is dynamic. The potential for interactions between the infant and the lactating person's immune system is an important area of research, but it is helpful to distinguish what is known about breast milk's immune function from explanations of how particular changes might be triggered. Does maternal diet affect breast milk? A varied, balanced diet supports the nutritional health of the lactating person. Some aspects of breast milk composition, including the profile of certain fatty acids, can be influenced by maternal dietary intake. However, the relationship between diet and the overall nutritional composition of breast milk is complex, and changes in what someone eats do not reliably produce a predictable increase in the total fat content of their milk or their baby's weight gain (Bravi et al., 2016; Dror and Allen, 2018). There is no special diet that is required to produce good-quality breast milk. In general, a balanced diet that includes a variety of foods is appropriate, and drinking to thirst is a reasonable way to maintain hydration. Drinking excessive amounts of fluid does not, by itself, increase milk production. Where there are concerns about a baby's weight gain, it is important to consider the whole feeding picture. This includes how effectively the baby feeds, milk transfer, feeding frequency, milk production and the infant's clinical circumstances. Changing the lactating person's diet alone is not a reliable way to address poor weight gain. How breast milk changes during a feed The fat concentration of breast milk changes as milk is removed from the breast. Rather than being divided into two distinct types, milk has a changing composition throughout a feed. Fat concentration generally increases as the breast becomes less full, although the pattern varies according to breast fullness, the interval since the previous feed and the circumstances of milk removal (Daly et al., 1993; Kent et al., 2006). The terms foremilk and hindmilk have traditionally been used to describe milk collected towards the beginning and end of a feed. However, these terms can give the misleading impression that one type of milk stops and another begins at a specific point. In reality, there is no abrupt transition. Milk with a lower fat concentration and milk with a higher fat concentration are part of the same continuously changing fluid, and their relative proportions vary throughout milk removal. The fat concentration at any particular moment depends on the circumstances of feeding. Milk at the beginning of one feed may have a different fat concentration from milk at the beginning of another. There is no universal point at which milk becomes higher in fat, and no requirement for a baby to reach a particular stage of a feed before receiving nutritionally valuable milk (Daly et al., 1993; Kent et al., 2006). Milk ejection and changes in milk fat Changes in fat concentration should not be confused with the milk ejection reflex, commonly called let-down. Milk ejection occurs when oxytocin causes specialised cells surrounding the milk-producing alveoli to contract, moving milk into the ducts and towards the nipple. This response can occur more than once during a feed (Neville, 2001). Milk ejection describes the movement of milk, whereas changes in fat concentration describe its composition. Although milk ejection and milk removal are related, a let-down is not a switch between two types of milk. Milk composition continues to vary as feeding progresses, including around successive milk ejections. Understanding concerns about milk fat The expression foremilk–hindmilk imbalance is sometimes used when families are concerned about symptoms such as green stools, wind, fussiness or frequent feeding. However, these observations alone do not establish that an infant is receiving too much milk with a lower fat concentration or too little milk with a higher fat concentration. Milk fat varies naturally, and research examining milk macronutrients has not established a consistent relationship that would allow a particular symptom or stool colour to be used to identify an imbalance (Brockway et al., 2024). It is therefore important not to draw conclusions about milk composition from these observations alone. There is no universal requirement to feed for a specified number of minutes or to follow a rigid schedule to ensure that a baby receives milk with a higher fat concentration. Feeding patterns need to be considered in the context of the individual infant, including feeding effectiveness, growth and any clinical concerns. Understanding a baby's feeding cues can help families respond to their individual needs without trying to manage feeding according to perceived changes in milk fat. For more information, see Recognising Feeding Cues in Young Babies. Where persistent symptoms, feeding difficulties or concerns about weight gain are present, assessment of the infant and the overall feeding pattern is more informative than attempting to correct an assumed imbalance. How breast milk changes as a child grows Breast milk changes throughout lactation. Colostrum, produced in the first days after birth, has a different composition from mature milk, including differences in its concentration of proteins and immune components. As milk production becomes established, its composition changes to meet the needs of the growing infant, although individual variation remains considerable (Ballard and Morrow, 2013). Breast milk continues to provide energy, nutrients and biologically active components beyond the first year of life. Research has found that milk composition can change during prolonged lactation, including changes in some macronutrients and immune components. These changes do not mean that breast milk loses its value as a child grows (Lackey et al., 2021). The World Health Organization recommends exclusive breastfeeding for the first six months, followed by the introduction of complementary foods alongside continued breastfeeding to two years and beyond (WHO, 2023). As children grow, complementary foods become necessary to meet their increasing nutritional requirements. Breast milk continues to contribute nutrition and biological support alongside those foods, including during natural-term breastfeeding, which may continue for several years until the child chooses to wean. A final perspective on breast milk Breast milk is a complex, biologically active food that provides energy, nutrients and immune components. Its composition changes naturally from colostrum in the early days after birth to mature milk and the milk produced during prolonged breastfeeding. These changes are part of normal lactation and do not mean that breast milk loses its value as a child grows. Understanding the biology of lactation can help explain why milk composition varies, how milk production works and why the idea of two separate types of milk is misleading. However, lactating parents do not need to understand these mechanisms to breastfeed. They do not need to monitor milk fat, identify different stages of milk composition or learn the science of lactation to feed their baby. The science behind breast milk is fascinating, but it should reassure families about the remarkable biology of lactation rather than create another expectation they feel they must meet. Where feeding is difficult or there are concerns about growth, appropriate support can help families understand what is happening and identify whether anything needs attention. References Association of Breastfeeding Mothers (2023) How Breastmilk Is Made [YouTube video]. Illustrated and animated by JoJo Ford. Available at: https://www.youtube.com/watch?v=5-i4tm7mGnc Ballard, O. and Morrow, A.L. (2013) ‘Human milk composition: nutrients and bioactive factors’, Pediatric Clinics of North America, 60(1), pp. 49–74. doi: 10.1016/j.pcl.2012.10.002. Bode, L. (2012) ‘Human milk oligosaccharides: every baby needs a sugar mama’, Glycobiology, 22(9), pp. 1147–1162. doi: 10.1093/glycob/cws074. Bravi, F. et al. (2016) ‘Impact of maternal nutrition on breast-milk composition: a systematic review’, The American Journal of Clinical Nutrition, 104(3), pp. 646–662. doi: 10.3945/ajcn.115.120881. Brockway, M.B. et al. (2024) ‘Human milk macronutrients and child growth and body composition in the first two years: a systematic review’, Advances in Nutrition, 15(1), article 100149. doi: 10.1016/j.advnut.2023.100149. Cacho, N.T. and Lawrence, R.M. (2017) ‘Innate immunity and breast milk’, Frontiers in Immunology, 8, article 584. doi: 10.3389/fimmu.2017.00584. 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. doi: 10.1113/expphysiol.1993.sp003722. Dror, D.K. and Allen, L.H. (2018) ‘Overview of nutrients in human milk’, Advances in Nutrition, 9(Suppl. 1), pp. 278S–294S. doi: 10.1093/advances/nmy022. Kent, J.C. et al. (2006) ‘Volume and frequency of breastfeedings and fat content of breast milk throughout the day’, Pediatrics, 117(3), pp. e387–e395. doi: 10.1542/peds.2005-1417. Lackey, K.A. et al. (2021) ‘Breastfeeding beyond 12 months: is there evidence for health impacts?’, Annual Review of Nutrition, 41, pp. 283–308. doi: 10.1146/annurev-nutr-043020-011242. National Health Service (NHS) (n.d.) Breastfeeding vitamins. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/healthy-diet-when-breastfeeding/breastfeeding-vitamins/ Neville, M.C. (2001) ‘Anatomy and physiology of lactation’, Pediatric Clinics of North America, 48(1), pp. 13–34. doi: 10.1016/S0031-3955(05)70283-2. Verhasselt, V. et al. (2024) ‘Antibodies in breast milk: pro-bodies designed for healthy newborn development’, Immunological Reviews, 328(1), pp. 192–204. doi: 10.1111/imr.13411. World Health Organization (WHO) (2023) WHO guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization.

Switch Nursing: Supporting Milk Supply, Milk Transfer and Infant Weight Gain Switch nursing is a breastfeeding technique that involves offering each breast more than once during a feed. It can be used when milk production needs increasing, when a baby is not maintaining active feeding or when an infant is struggling to gain weight as expected. By changing breasts when sucking and swallowing slow, the aim is to encourage renewed feeding activity, stimulate further milk ejection reflexes and support effective milk removal (Riordan and Wambach, 2016; La Leche League Canada, 2024). Switch nursing is not simply a way to manage a baby who comes off the breast, dozes and then signals to feed again. It is a practical technique that may form part of a wider feeding plan, particularly when milk production or milk transfer needs support. Understanding when and how to use it, alongside other strategies, helps ensure that feeding advice addresses the needs of the individual feeding dyad rather than focusing solely on how long a baby remains at the breast. What is switch nursing? Switch nursing involves offering one breast until the baby's active sucking and swallowing slows, then offering the other breast. If active feeding slows again, the first breast can be offered once more, with further changes of side as appropriate. This may be repeated several times during a single feed, depending on the baby's response and the feeding plan (Riordan and Wambach, 2016; La Leche League Canada, 2024). The intention is to encourage periods of active feeding rather than allowing a baby to spend a prolonged time at the breast with little effective milk transfer. Nutritive sucking is generally characterised by deeper, slower jaw movements and swallowing, whereas non-nutritive sucking tends to involve more rapid, shallow movements with less swallowing. Observing these changes can help identify when a baby may benefit from breast compressions or a change of side (Academy of Breastfeeding Medicine, 2022; University Health Network, 2020). Changing breasts can stimulate another milk ejection reflex, providing an opportunity for the baby to resume more active sucking and swallowing. Repeated breast stimulation may also contribute to maintaining or increasing milk production when combined with effective milk removal across the day and night (Riordan and Wambach, 2016; Kent et al., 2006). Switch nursing does not require equal feeding times on each breast, and there is no universally correct number of switches. The approach depends on the baby's feeding behaviour, milk transfer, clinical needs and the breastfeeding parent's goals. When might switch nursing be useful? Switch nursing may be considered when milk production needs increasing, when a baby becomes sleepy before feeding effectively, or when active sucking and swallowing reduce before sufficient milk has been transferred. It may also be incorporated into a feeding plan when an infant's weight gain is slower than expected and assessment suggests that encouraging more active feeding could help (Riordan and Wambach, 2016; University Hospitals Sussex NHS Foundation Trust, n.d.). When milk production needs increasing, offering both breasts and returning to each side may provide additional stimulation. If a baby is becoming less active as milk flow slows, changing breasts can offer another opportunity for active feeding. Breast compressions can also be used to encourage milk flow before changing sides (La Leche League Canada, 2024). However, frequent feeding does not automatically indicate low milk production. Cluster feeding can be part of normal infant feeding behaviour, and feeding frequency varies between babies and across the day. The significance of frequent feeding depends on the wider picture, including the baby's health, feeding effectiveness, urine output, growth and the breastfeeding parent's experience (Kent et al., 2006; Academy of Breastfeeding Medicine, 2022). Switch nursing is therefore best understood as one technique that may support effective feeding and milk removal, rather than a solution for every unsettled feed or every concern about supply. Where feeding difficulties persist, assessment is needed to establish whether the main concern relates to milk production, milk transfer, infant feeding function or another contributing factor. Combining switch nursing with breast compressions Breast compressions involve gently compressing the breast while the baby is attached, with the intention of encouraging milk flow. When a baby continues sucking but swallowing slows, compression may help the baby receive more milk before changing sides. Once the baby is no longer responding to compression, offering the other breast may encourage renewed sucking and swallowing (La Leche League Canada, 2024; University Hospitals Sussex NHS Foundation Trust, n.d.). The two techniques can be combined according to the baby's response. A caregiver may observe active feeding on the first breast, use breast compressions when swallowing slows, and then offer the other breast if the baby remains interested but is no longer feeding effectively. The sequence can be repeated as appropriate. The aim is to support milk transfer without causing pain or turning feeding into a rigid routine. Breast compression should be comfortable, and the baby should not be forced to remain attached when no longer interested or when feeding appears difficult. Persistent difficulty maintaining attachment, coordinating sucking and swallowing or responding to milk flow warrants further assessment rather than repeated switching alone (Academy of Breastfeeding Medicine, 2022). Positioning, attachment and breast shaping Effective positioning and attachment are important because the baby's ability to maintain a comfortable latch influences milk transfer. If a baby repeatedly slips off the breast, struggles to maintain attachment or causes persistent nipple pain, switching sides may not resolve the underlying difficulty. A feeding assessment can help identify whether positioning, attachment, oral function or another factor needs attention (Academy of Breastfeeding Medicine, 2022; NICE, 2017). Breast shaping can support some babies to achieve an effective attachment by helping the breast fit comfortably within the baby's mouth. The approach needs to take account of the baby's position, the shape and size of the breast, nipple direction and the breastfeeding parent's comfort. Breast shaping, positioning and attachment should be considered together rather than as separate rules that every feeding dyad must follow. For further information, see Breastfeeding Latch and Positioning and How to Improve Infant Latch: Practical Breastfeeding Support. Where attachment remains difficult despite support, the assessment should consider the baby's feeding function and the wider clinical picture. The appearance of a lingual frenulum alone does not establish whether it is affecting feeding; assessment needs to consider tongue function, observed feeding, maternal comfort and milk transfer (NICE, 2017). Supporting milk production Milk production is influenced by hormonal processes and the frequency and effectiveness of milk removal. In the early postnatal period, frequent breastfeeding and effective milk removal are important in establishing production, while ongoing milk removal helps regulate production in response to the infant's needs (de Carvalho et al., 1983; Kent et al., 2006). Where supply needs increasing, switch nursing may be one component of a plan to provide additional breast stimulation. Other measures may include responsive feeding, improving attachment, breast compressions and expressing milk. The appropriate combination depends on the reason for the supply concern and whether the baby can remove milk effectively at the breast (Academy of Breastfeeding Medicine, 2017; Academy of Breastfeeding Medicine, 2022). It is important to distinguish between milk production and milk transfer. A breastfeeding parent may produce sufficient milk, but an infant may struggle to remove it effectively. Alternatively, the infant may feed effectively but the available milk may not meet their needs. Both situations can involve frequent feeding, yet the management approach may differ (NICE, 2017; Kent et al., 2006). Further information is available in Increasing Breast Milk Production. This can help families understand why assessment of milk production and milk removal matters before assuming that supply is the sole explanation for feeding difficulties. Expressing milk and flange fit Expressing may be helpful when an infant is unable to remove sufficient milk directly from the breast, when a feed is missed or ineffective, or when additional stimulation is needed to support milk production. Expressed breast milk can also be offered to the infant when additional intake is required as part of an agreed feeding plan (Academy of Breastfeeding Medicine, 2017; Academy of Breastfeeding Medicine, 2022). The frequency of expressing should reflect the individual circumstances, including the baby's age, feeding effectiveness, milk production and the amount of additional milk required. Where an infant is not transferring milk effectively, expressing may help protect milk production while the underlying difficulty is assessed and addressed. It should not, however, become an unnecessarily burdensome routine without consideration of the mother's recovery, sleep, emotional wellbeing and practical circumstances. Pump choice and flange fit can affect comfort and the experience of expressing. A flange that is unsuitable for the individual breast and nipple may cause discomfort or contribute to ineffective milk removal, so assessment of fit can be valuable when expressing is painful or appears ineffective (Academy of Breastfeeding Medicine, 2022). Families can read more in How to Express Breastmilk and Breast Pump Flange Fitting: Size, Shape, Comfort and Milk Removal. Low weight gain: why weighing alone is not enough When an infant's weight trajectory raises concern, weight measurements are essential for identifying the pattern of growth and monitoring whether progress is improving. However, weighing is a monitoring measure, not an intervention that addresses the cause of inadequate weight gain. NICE recommends a clinical, developmental and social assessment when faltering growth is suspected, alongside a detailed feeding history and direct observation of feeding where appropriate. For milk-fed infants, possible contributing factors include ineffective suckling, ineffective bottle feeding, feeding patterns, the feeding environment, feeding aversion, responses to feeding cues and physical difficulties affecting feeding (NICE, 2017). This distinction is important because a baby may feed frequently without transferring sufficient milk, while another may transfer milk effectively but have an underlying issue affecting milk production or growth. Weight measurements can demonstrate that a concern exists, but they cannot establish the cause by themselves. The assessment and feeding plan must address the factors contributing to the baby's growth trajectory (NICE, 2017). Where weight gain is concerning, timely involvement of an appropriate healthcare professional is a priority. The urgency depends on the baby's age, clinical condition, degree of weight change and other findings. A baby who is unwell, difficult to wake, showing signs of dehydration or feeding substantially less than usual needs urgent clinical assessment rather than further attempts to manage feeding with switch nursing alone (NICE, 2017). An International Board Certified Lactation Consultant (IBCLC) can provide specialist lactation and infant-feeding assessment, including observation of feeding, assessment of milk transfer and support with milk production, expressing and supplementation. The IBCLC can contribute to a feeding plan alongside the GP, health visitor, midwife or paediatric team, according to the baby's clinical needs. Medical assessment remains necessary where illness, dehydration or another health concern needs to be investigated (NICE, 2017; Academy of Breastfeeding Medicine, 2022). The baby's health and adequate nutritional intake must come first. Increasing milk production may be an important part of the plan, particularly where continued breastfeeding is a family goal, but it must not delay ensuring that the infant receives sufficient milk. The plan may include switch nursing, breast compressions, improving attachment, expressing and providing additional milk where clinically indicated. Follow-up should evaluate whether the plan is meeting the baby's nutritional needs and whether the factors contributing to the concern are improving, alongside weight monitoring at intervals appropriate to the clinical situation (NICE, 2017; Kellams et al., 2017). For more information about specialist feeding support, see What is an IBCLC? Feeding Support Explained. Expressed milk, supplementation and supplemental nursing systems Where an infant needs additional milk, the feeding plan should identify how their nutritional requirements will be met while the underlying difficulty is investigated and addressed. Depending on the clinical circumstances, this may involve expressed breast milk, donor human milk where available and appropriate, or infant formula. Supplementation decisions should be based on an assessment of the individual infant rather than a single finding in isolation (Kellams et al., 2017). Providing additional milk does not automatically mean breastfeeding must end. Where maintaining breastfeeding is important to the family, the plan may include continuing to offer the breast when appropriate, expressing to support milk production and reviewing the approach as feeding effectiveness and growth improve. The infant's immediate nutritional needs must remain central to these decisions (Kellams et al., 2017; NICE, 2017). A supplemental nursing system (SNS) delivers additional milk through a fine tube positioned alongside the nipple, allowing the baby to receive milk while feeding at the breast. For some feeding dyads, this can be an option for providing additional milk while maintaining opportunities for direct breastfeeding and breast stimulation. Suitability depends on the baby's feeding ability, the amount of milk required and whether the system can be used reliably and safely with appropriate guidance (La Leche League Great Britain, n.d.; Kellams et al., 2017). An SNS should not be selected simply because an infant has a low weight trajectory. Assessment needs to establish whether the baby can feed effectively at the breast, whether the system is practical for the family and whether the baby's nutritional needs can be met using that method. Other alternative feeding methods may be more appropriate in some circumstances (Kellams et al., 2017). Further information is available in Alternative Feeding Methods for Babies, which discusses different approaches to providing milk when feeding directly at the breast is insufficient or not possible. Supporting maternal mental health during feeding difficulties Breastfeeding difficulties can affect emotional wellbeing, particularly when a mother is worried about milk production, feels that her baby is not satisfied after feeding or is receiving repeated advice to change how she feeds. When an infant is not gaining weight as expected, the responsibility of ensuring adequate intake can add to anxiety, exhaustion and feelings of uncertainty. Frequent feeding, expressing, monitoring intake and attending additional appointments can also become physically and emotionally demanding (World Health Organization, 2022; NICE, 2017). Support should recognise the mother's experience alongside the baby's feeding needs. Reassurance alone may not be sufficient when feeding remains difficult or there are unresolved concerns about milk transfer or weight gain. Clear explanations, an achievable feeding plan, appropriate clinical follow-up and consistent communication between healthcare professionals can help reduce uncertainty and ensure that responsibility for resolving the difficulty does not rest entirely on the mother (World Health Organization, 2022). Switch nursing and other breastfeeding techniques should be offered when appropriate to the feeding assessment, rather than becoming additional tasks that a mother feels she must perform perfectly. Where expressing, supplementation or other feeding methods are needed, these should be discussed sensitively, taking account of the mother's circumstances, feeding goals and emotional wellbeing. Supporting the baby's nutritional needs and supporting the mother's mental health are complementary priorities (World Health Organization, 2022; Kellams et al., 2017). Healthcare professionals should remain alert to signs of significant distress, anxiety or low mood and facilitate access to appropriate perinatal mental-health support when needed. The World Health Organization recommends psychosocial interventions to help prevent postnatal depression and anxiety and emphasises the importance of supportive, respectful postnatal care (World Health Organization, 2022). A compassionate approach acknowledges that feeding experiences can be emotionally complex and that seeking help is not a sign of failure. When feeding difficulties persist Persistent feeding difficulties may involve several contributing factors, including positioning and attachment, maternal comfort, milk production, infant alertness, oral function, coordination, underlying illness or other clinical and environmental influences. NICE recommends considering a range of possible factors when assessing faltering growth, rather than assuming that one explanation accounts for every feeding difficulty (NICE, 2017). A lingual frenulum may be relevant to feeding function in some infants, but its appearance alone cannot establish whether it is affecting feeding. Assessment should consider tongue function, observed feeding, maternal comfort, milk transfer and the baby's wider clinical picture (NICE, 2017). Where a baby repeatedly falls asleep before feeding effectively, struggles to maintain attachment, has difficulty coordinating sucking and swallowing or continues to gain weight inadequately, further assessment is more important than repeatedly changing breasts in the hope that the problem will resolve. The appropriate feeding strategy should follow the assessment and be reviewed according to the baby's response (Academy of Breastfeeding Medicine, 2022; NICE, 2017). For professionals supporting feeding dyads, documenting the presenting concern, observed feeding behaviour, parental comfort, agreed feeding plan and review arrangements can support continuity of care. This also helps ensure that a technique is reviewed when it is not meeting the baby's needs, rather than continuing without evidence of improvement (Academy of Breastfeeding Medicine, 2022). The role of switch nursing in a wider feeding plan Switch nursing can be a useful technique for encouraging active feeding and providing additional breast stimulation. It may be considered when milk production needs increasing or when a baby becomes less active at the breast before feeding effectively. It can be combined with breast compressions, effective positioning and attachment, breast shaping and expressing where appropriate (Riordan and Wambach, 2016; La Leche League Canada, 2024). However, the aim is not to keep a baby at the breast for as long as possible or to increase the number of switches without considering the outcome. The important questions are whether the baby is transferring milk effectively, receiving adequate nutrition, maintaining hydration and growing as expected (NICE, 2017; Academy of Breastfeeding Medicine, 2022). When weight gain is concerning, weighing provides information about progress, but the feeding plan must address the factors contributing to the concern. Specialist infant-feeding support and appropriate healthcare involvement can help families understand what is happening, protect the baby's health and support milk production where needed. The mother's emotional wellbeing also deserves attention throughout this process (NICE, 2017; World Health Organization, 2022). The most useful feeding strategy is one that meets the baby's nutritional needs, supports the family's feeding goals and is reviewed according to the response of the individual feeding dyad. References Academy of Breastfeeding Medicine (2017) ‘ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017’, Breastfeeding Medicine, 12(3), pp. 188–198. doi: 10.1089/bfm.2017.29038.ajk. 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. doi: 10.1089/bfm.2022.29203.aeh. de Carvalho, M., Robertson, S., Merkatz, R. and Klaus, M. (1983) ‘Effect of frequent breastfeeding on early milk production and infant weight gain’, Pediatrics, 72(3), pp. 307–311. Kellams, A., Harrel, C., Omage, S., Gregory, C. and Rosen-Carole, C. (2017) ‘ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017’, Breastfeeding Medicine, 12(3), pp. 188–198. doi: 10.1089/bfm.2017.29038.ajk. Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A. and Hartmann, P.E. (2006) ‘Volume and frequency of breastfeedings and fat content of breast milk throughout the day’, Pediatrics, 117(3), pp. e387–e395. doi: 10.1542/peds.2005-1417. La Leche League Canada (2024) Breast compressions and switch nursing. Available at: https://www.lllc.ca/breast-compressions-and-switch-nursing. La Leche League Great Britain (n.d.) Relactation and induced lactation. Available at: https://laleche.org.uk/relactation-induced-lactation/. National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. Available at: https://www.nice.org.uk/guidance/ng75. Riordan, J. and Wambach, K. (2016) Breastfeeding and human lactation. 5th edn. Burlington, MA: Jones & Bartlett Learning. University Hospitals Sussex NHS Foundation Trust (n.d.) Helping your breastfed baby to get all the milk they need. Available at: https://www.uhsussex.nhs.uk/resources/helping-your-breastfed-baby-to-get-all-the-milk-they-need-2/. World Health Organization (2022) WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240045989. World Health Organization (2022) WHO guide for integration of perinatal mental health in maternal and child health services. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240057142.

Tongue-tie, also known as ankyloglossia, describes a lingual frenulum that restricts tongue movement. However, identifying a restrictive frenulum does not, in itself, establish that surgical division is necessary. Assessment needs to consider the infant’s oral function, feeding difficulties, clinical history and whether the potential benefits of division outweigh the risks for that individual baby (NICE, 2005). One important part of pre-procedure assessment is identifying any known or suspected condition that could affect blood clotting. Some conditions interfere with the body’s ability to stop bleeding, while others increase the tendency for blood clots to develop within blood vessels. These are different clinical issues, and the distinction matters when considering the suitability, setting and timing of a surgical procedure. Although many bleeding and clotting disorders are uncommon, a relevant family history or previously undiagnosed condition may not be apparent from an infant’s general appearance. A baby may appear well and have no history of previous surgery or significant injury, yet still have an inherited bleeding disorder. Conversely, a family history of thrombophilia does not automatically mean that an infant has the condition or that tongue-tie division is necessarily contraindicated. This article explores the differences between bleeding disorders and thrombophilia, the information that may be relevant before tongue-tie division, and circumstances in which further assessment or specialist advice may be needed. Understanding the two sides of blood clotting Blood clotting, or haemostasis, is a complex process involving blood vessels, platelets and clotting proteins known as coagulation factors. These work together to limit blood loss when a blood vessel is injured. If the process is impaired, bleeding may be prolonged or excessive. If the balance is disrupted in the opposite direction, abnormal clots may form within the circulation (NHS, n.d.-a; NHS, n.d.-b). Bleeding disorders include conditions such as haemophilia A, haemophilia B, von Willebrand disease, certain clotting-factor deficiencies and platelet disorders. Their severity varies considerably. Some cause relatively mild symptoms, whereas others can result in serious bleeding following an injury, operation or other invasive procedure (NHS, n.d.-a; NHS, n.d.-c). Thrombophilia describes an increased tendency to develop abnormal blood clots. It can be inherited or acquired, and examples include factor V Leiden, the prothrombin gene variant G20210A, deficiencies of antithrombin, protein C or protein S, and antiphospholipid syndrome (NHS, n.d.-b). Thrombosis occurs when a blood clot develops within a blood vessel. If part of a clot breaks away and travels through the circulation before lodging elsewhere, it is called an embolus. A pulmonary embolism occurs when a clot blocks a blood vessel in the lungs and can be life-threatening (NHS, n.d.-b). These are important consequences of thrombophilia to understand, but they should not be confused with established complications of a particular procedure. The presence of thrombophilia does not, by itself, establish that a particular procedure is contraindicated or that an embolism is likely to occur following it. Equally, it should not be treated as irrelevant when an individual infant’s medical history raises concerns. The significance of a diagnosis depends on the particular condition, the infant’s circumstances and the clinical assessment. It is also important to distinguish factor V deficiency from factor V Leiden. Factor V deficiency is a rare bleeding disorder in which insufficient factor V is available for normal clot formation. Factor V Leiden is an inherited genetic variant associated with an increased tendency to develop abnormal blood clots. Despite the similar names, they have different implications for assessment (NHS, n.d.-b; UKHCDO, n.d.). Which conditions may affect the decision to divide? The following table provides an overview of conditions that may be relevant to a pre-procedure history. It is not an exhaustive diagnostic list, and it should not be used as a stand-alone decision tool. A diagnosis does not have the same implications for every infant, and the significance of a condition depends on its type, severity and clinical context. | Individual condition | Hereditary or acquired? | Associated risk | |---|---|---| | Haemophilia A (factor VIII deficiency) | Usually inherited; acquired cases are rare | Prolonged or serious bleeding | | Haemophilia B (factor IX deficiency) | Usually inherited; acquired cases are rare | Prolonged or serious bleeding | | Von Willebrand disease | Usually inherited; acquired forms also occur | Impaired platelet adhesion and clot formation, potentially causing prolonged bleeding | | Fibrinogen disorders (factor I) | Usually inherited; acquired abnormalities can occur | May cause bleeding, thrombosis or both, depending on the disorder | | Prothrombin deficiency (factor II) | Usually inherited; acquired deficiency can occur | Bleeding due to impaired clot formation | | Factor V deficiency | Usually inherited; acquired deficiency can occur | Bleeding | | Factor VII deficiency | Usually inherited; acquired deficiency can occur | Bleeding of variable severity | | Factor X deficiency | Usually inherited; acquired deficiency can occur | Bleeding | | Factor XI deficiency | Usually inherited; acquired deficiency can occur | Bleeding risk varies and may be more apparent following procedures involving mucosal tissue | | Factor XIII deficiency | Usually inherited; acquired deficiency can occur | Potentially serious bleeding; routine screening coagulation tests may be normal | | Inherited platelet-function disorders | Usually inherited | Impaired primary haemostasis and potentially prolonged mucosal or wound bleeding | | Thrombocytopenia | Acquired or inherited | A reduced platelet count may increase bleeding risk, depending on the cause and severity | | Vitamin K deficiency bleeding (VKDB) | Acquired | Reduced activity of vitamin K-dependent clotting factors, potentially causing serious bleeding | | Liver disease affecting coagulation | Acquired, inherited or associated with other conditions | May cause bleeding abnormalities and, in some circumstances, increased thrombosis risk | | Disseminated intravascular coagulation (DIC) | Acquired | Abnormal clot formation and potentially serious bleeding | | Factor V Leiden | Inherited | Increased tendency to develop abnormal blood clots; not the same as factor V deficiency | | Prothrombin gene variant G20210A | Inherited | Increased tendency to develop abnormal blood clots | | Antithrombin deficiency | Usually inherited; acquired reductions also occur | Increased tendency to develop abnormal blood clots | | Protein C deficiency | Usually inherited; acquired deficiency can occur | Increased tendency to develop abnormal blood clots | | Protein S deficiency | Usually inherited; acquired deficiency can occur | Increased tendency to develop abnormal blood clots | | Antiphospholipid syndrome (APS) | Acquired autoimmune condition | Increased tendency to develop thrombosis; pregnancy complications may also occur | | Alpha- or beta-thalassaemia | Inherited | Primarily affects haemoglobin production and oxygen transport; it is not a primary coagulation disorder | The conditions listed above vary considerably in their severity and clinical implications, and this table is intended to provide general information rather than determine an infant’s suitability for surgery. Where an infant has a known or suspected bleeding disorder, thrombophilia or another condition that may affect haemostasis, the practitioner should seek advice from the healthcare professional accountable for the infant’s relevant medical care before making a decision about tongue-tie division. Where the implications remain uncertain or further assessment is needed, referral to an appropriate medical or specialist service should be arranged. Neither the condition’s name alone nor this table should be used as a substitute for individual clinical assessment. The distinction between bleeding disorders and thrombophilia remains important. A condition associated with abnormal clot formation does not necessarily cause excessive bleeding, while a condition that impairs haemostasis may create a direct concern when an incision is made. Some disorders, including certain fibrinogen abnormalities and liver-related coagulation disturbances, can involve both bleeding and thrombosis. What the family history can reveal A family history can provide important information when assessing an infant before a surgical procedure. Asking whether close relatives have been diagnosed with a bleeding disorder, experienced unexplained excessive bleeding, or developed blood clots at an unusually young age may identify a reason for further assessment. Relevant questions include whether anyone in the family has haemophilia, von Willebrand disease, a known clotting-factor deficiency, an inherited platelet disorder or a diagnosed thrombophilia. A history of unexplained bleeding after surgery, dental treatment or childbirth may also be relevant, particularly if the bleeding was prolonged or required additional treatment (NHS, n.d.-a; NHS, n.d.-c). A family history of thrombosis may be significant where a close relative has a confirmed inherited thrombophilia or experienced an unexplained blood clot at a young age. However, a relative having had a blood clot does not establish that the infant has an inherited condition. Blood clots can occur for several reasons, and the circumstances surrounding the event matter. The inheritance pattern also needs to be understood. Haemophilia A and haemophilia B are usually X-linked conditions. A mother who carries an affected gene may pass it to her children. Sons who inherit the affected gene are more likely to have haemophilia, while daughters who inherit it are often carriers, although some have bleeding symptoms themselves. A father with haemophilia passes his affected X chromosome to his daughters, but not to his sons, because sons inherit their father’s Y chromosome (NHS, n.d.-a). Other inherited bleeding disorders and thrombophilias follow different inheritance patterns. Some may affect children of any sex, and some require a child to inherit an altered gene from both biological parents before the condition develops in its more severe form. It is therefore important not to assume that a condition will follow a particular side of the family or affect only boys. A negative family history cannot exclude every inherited disorder. Relatives may have mild symptoms that were never investigated, a condition may have arisen through a new genetic change, or the family may not know the relevant medical history. Family history is one part of assessment, not a substitute for clinical judgement. Recognising possible warning signs in the mother or baby The absence of a diagnosed condition does not always mean that there is no relevant history. A practitioner should remain alert to information that could indicate an underlying bleeding disorder or another medical concern. In an infant, potentially relevant features include unusual or extensive bruising, bleeding that appears disproportionate to an injury, prolonged bleeding after a heel-prick blood test or another procedure, blood in the urine or stool, or a known history of unexplained bleeding. These signs do not establish a diagnosis, but they may warrant medical assessment before an elective procedure is considered (NHS, n.d.-a; NHS, n.d.-c). A history of significant bleeding in the birthing parent may also be relevant, particularly if it was unexplained or disproportionate to the circumstances. Examples include excessive bleeding after childbirth, persistent bleeding after dental treatment or surgery, frequent nosebleeds, easy bruising or unusually heavy menstrual bleeding. These symptoms have multiple possible causes, and they should not be used in isolation to diagnose a bleeding disorder. Likewise, a history of thrombosis, recurrent pregnancy loss or a confirmed thrombophilia may justify clarification of the diagnosis and its relevance to the infant. Recurrent pregnancy loss can be associated with antiphospholipid syndrome, but it is not proof that a parent or infant has a particular clotting disorder (NHS, n.d.-b). If an infant has unexplained bleeding, significant bruising, blood in the stool or urine, or other concerning symptoms, the priority is medical assessment rather than proceeding with an elective frenulotomy. Acute or substantial bleeding requires urgent assessment. The purpose of recognising warning signs is not to diagnose a condition in the clinic, but to identify when the available information is insufficient to make a safe decision. The practical pre-procedure history A structured history helps ensure that relevant information is considered consistently. The questions should be proportionate to the infant’s circumstances and include any known diagnosis, medication, previous bleeding and relevant family history. Before tongue-tie division, it is useful to establish whether the infant has a diagnosed bleeding disorder, thrombophilia, liver condition or other illness that could affect haemostasis; whether there has been unusual bleeding or bruising; whether the infant has previously undergone a procedure; and whether a close relative has a confirmed inherited bleeding or clotting disorder. The vitamin K history is particularly important. The practitioner should establish whether vitamin K was offered and administered, whether the course was completed where oral prophylaxis was chosen, and whether there are any concerns about possible vitamin K deficiency bleeding. The absence of obvious symptoms does not establish that an infant has no bleeding risk. The history should also identify medicines or treatments that may affect coagulation, any known abnormal blood-test results and any advice previously provided by a paediatrician, haematologist or other specialist. If a diagnosis is reported by the family, it may be necessary to clarify the precise condition rather than relying on a broad description such as “a clotting problem”. A routine history cannot identify every disorder, and normal examination findings do not exclude all bleeding conditions. Equally, not every infant requires a full panel of coagulation tests. The decision to investigate should be guided by the history, examination, known diagnoses and relevant clinical guidance. Where a concern cannot be resolved within the practitioner’s competence or available service, the appropriate next step is to seek medical or specialist advice rather than make assumptions. What maternal screening and genetics can tell us Families may understandably assume that routine antenatal blood tests would have identified a blood disorder that could affect a baby’s suitability for surgery. However, routine antenatal screening does not test every pregnant person for all inherited bleeding disorders or thrombophilias. In England, antenatal screening is offered for sickle cell and thalassaemia and other relevant haemoglobin disorders through the NHS screening programme. These are inherited blood disorders that affect haemoglobin and the blood’s ability to carry oxygen; they are not the same as the coagulation-factor deficiencies associated with conditions such as haemophilia (NHS, n.d.-d; NHS England, 2024). There is no universal antenatal screening programme that identifies every case of haemophilia, von Willebrand disease, factor deficiency, platelet-function disorder or inherited thrombophilia. Testing may be offered when there is a relevant family history, previous diagnosis, clinical concern or another indication. The absence of a diagnosis during pregnancy therefore cannot be interpreted as proof that every possible inherited bleeding or clotting disorder has been excluded (NHS, n.d.-a; NHS, n.d.-b). Where a parent is known to have an inherited condition, genetic counselling or specialist advice may help clarify the likelihood of the infant being affected. The implications depend on the particular condition and its inheritance pattern. A carrier parent may pass on a genetic variant without the child necessarily developing the same condition or degree of severity. Antiphospholipid syndrome requires a separate distinction. It is an acquired autoimmune condition associated with increased clotting risk, rather than a straightforward inherited thrombophilia. A maternal diagnosis does not, in itself, mean that the infant has APS. The family history should be interpreted in context rather than used to infer an infant diagnosis. Vitamin K, jaundice and acquired bleeding risk Vitamin K is essential for the production of several clotting factors. Babies are born with relatively low vitamin K stores, and vitamin K deficiency bleeding can occur if there is insufficient vitamin K for normal clotting. Although uncommon, this can be serious, including in infants who initially appear well (NICE, 2021; NICE, 2026). The history of vitamin K administration should therefore form part of the pre-procedure assessment. If vitamin K was declined, not administered or an oral course was not completed, this information needs to be considered alongside the infant’s age, health and clinical history. It should not be treated as a diagnosis of vitamin K deficiency, but it may mean that the practitioner cannot assume the usual prophylactic protection has been provided. Jaundice also warrants careful consideration. Prolonged or unexplained jaundice can sometimes be associated with underlying illness, including conditions that affect the liver or bile flow. Since the liver produces many proteins involved in coagulation, significant liver disease may affect haemostasis. However, jaundice alone does not establish liver disease or a clotting abnormality; its cause and the infant’s overall condition need to be assessed in accordance with relevant clinical guidance (NICE, 2010, updated 2023). For further information on vitamin K and tongue-tie division, see Vitamin K and Tongue-tie Division. When to seek specialist advice and how to access it Medical or specialist advice may be needed when the history identifies a diagnosed bleeding disorder, a suspected significant coagulation abnormality, unexplained bleeding or bruising, or an inherited condition whose implications for the proposed procedure are unclear. For known or suspected haemophilia, factor deficiency, von Willebrand disease or a significant platelet disorder, advice from a paediatric haematology service or haemophilia centre may be needed to establish whether division is appropriate and what arrangements would be required to manage bleeding. The relevant specialist team can advise on investigations, treatment and the appropriate setting for any procedure (NHS England, 2025; UKHCDO, n.d.). Where thrombophilia is known or suspected, the decision should reflect the specific diagnosis and the infant’s clinical circumstances. Specialist advice may be appropriate when there is a known significant disorder, a personal history of thrombosis, additional medical complexity or uncertainty about how the condition affects the proposed care. A family history or diagnosis of thrombophilia should not automatically be equated with a contraindication to division, but it should not be dismissed without considering its relevance. If the practitioner cannot establish whether a reported condition is significant, whether further assessment is required or whether the proposed setting is appropriate, the decision should be deferred while suitable advice is obtained. Where the question falls outside the practitioner’s scope of practice or cannot be resolved within the service, referral to the infant’s GP, paediatrician, haematology service or another appropriate healthcare professional should be considered according to the nature of the concern. This is not the same as automatically excluding every infant with a clotting-related diagnosis from consideration for division. Where advice establishes that a procedure can be undertaken with appropriate arrangements, the plan should be clear before proceeding. Where the risk cannot be adequately assessed or managed within the available service, referral to a more appropriate setting may be necessary. Community practice, hospital care and whether division is appropriate The decision about whether tongue-tie division is appropriate involves more than identifying a frenulum or reviewing one risk factor. It requires consideration of the infant’s feeding function, the expected benefit of intervention, the clinical history, relevant examination findings, the practitioner’s scope of practice and the ability to respond to foreseeable complications. A known bleeding disorder may require a specialist management plan, access to treatment or a setting with facilities that are not available in a community clinic. In these circumstances, proceeding without the necessary assessment or arrangements would not be appropriate. The precise requirements depend on the condition and the advice of the relevant clinical team. Thrombophilia needs to be considered differently from a bleeding disorder. An inherited tendency to develop blood clots does not necessarily mean that a brief procedure involving the lingual frenulum is contraindicated, and thrombophilia should not automatically be treated as requiring hospital-based frenulotomy. However, the specific diagnosis, the infant’s medical history and any other risk factors remain relevant to an individual decision. The available literature on complications following infant tongue-tie release describes concerns including bleeding, feeding difficulties and respiratory or airway events. A systematic review of major complications does not identify embolism as an established complication of frenulotomy (Solis-Pazmino et al., 2020). This should not be interpreted as proof that every theoretical risk is impossible, but it is important not to present embolism as a recognised complication of the procedure without supporting evidence. The distinction is between the general risks associated with an underlying condition and complications established as associated with the procedure itself. Thrombophilia can be associated with serious thrombotic events, including pulmonary embolism, but this does not establish that an embolism is likely to occur because a tongue-tie division has been performed. The condition nevertheless warrants appropriate consideration when it is part of the infant’s known medical history. The practitioner should not use this article, or any general list of conditions, as a substitute for an individual assessment. Nor should a diagnosis be treated as an automatic decision either for or against intervention. Where the history raises a concern that cannot be adequately assessed within the service, the appropriate response is to obtain further advice, investigate where indicated or refer to a more suitable setting. Making decisions that prioritise the baby A restrictive lingual frenulum may contribute to feeding difficulties, but not every infant with a visible or palpable restriction requires surgical division. A functional assessment helps establish whether tongue movement is affecting feeding and whether division is likely to provide a meaningful benefit. Further information is available in A Guide to Understanding Your Baby’s Oral Function and Infant Oral Anatomy: Structure, Function and Feeding. When division is being considered, the assessment should include the infant’s clinical history, any relevant family history and factors that could affect bleeding or clotting. Where a known or suspected condition creates uncertainty, it is important to establish whether further assessment or specialist advice is needed before proceeding. Bleeding disorders and thrombophilia should not be treated as interchangeable. An underlying bleeding disorder may have direct implications for wound haemostasis, while thrombophilia relates to an increased tendency to form abnormal blood clots. Some conditions can involve more complex patterns of both bleeding and thrombosis, so the precise diagnosis matters. The absence of a known diagnosis does not guarantee that an infant has no underlying disorder, and the presence of a diagnosis does not always dictate a single outcome. The aim is to recognise relevant concerns, understand the limitations of the available information and make an informed decision about whether division is appropriate and, if so, where and under what arrangements it should take place. A careful history, appropriate clinical judgement and timely medical or specialist input where indicated help ensure that decisions are made in the infant’s best interests, without either overlooking relevant risks or excluding babies from consideration solely because a condition has been named. References Haemophilia Society (n.d.) Treatment centres and support for people affected by bleeding disorders. Available at: https://haemophilia.org.uk/ Laffan, M. et al. (2024) ‘Guideline on the diagnosis and management of von Willebrand disease’, British Journal of Haematology. Available at: https://doi.org/10.1111/bjh.19385 National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance IPG149. Available at: https://www.nice.org.uk/guidance/ipg149 National Institute for Health and Care Excellence (NICE) (2010, updated 2023) Jaundice in newborn babies under 28 days. Clinical guideline CG98. Available at: https://www.nice.org.uk/guidance/cg98 National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. Guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194 NHS (n.d.-a) Haemophilia. Available at: https://www.nhs.uk/conditions/haemophilia/ NHS (n.d.-b) Thrombophilia. Available at: https://www.nhs.uk/conditions/thrombophilia/ NHS (n.d.-c) Von Willebrand disease. Available at: https://www.nhs.uk/conditions/von-willebrand-disease/ NHS (n.d.-d) Screening for sickle cell and thalassaemia. Available at: https://www.nhs.uk/pregnancy/your-pregnancy-care/screening-for-sickle-cell-and-thalassaemia/ NHS England (2024) Sickle cell and thalassaemia screening programme. Available at: https://www.gov.uk/government/collections/nhs-sickle-cell-and-thalassaemia-sct-screening-programme NHS England (2025) Consultation on service specification for haemophilia and related bleeding disorders (adults and children): background information. Available at: https://www.england.nhs.uk/long-read/consultation-on-service-specification-for-haemophilia-and-related-bleeding-disorders-adults-and-children-background-information/ Solis-Pazmino, P. et al. (2020) ‘Major complications after tongue-tie release: A case report and systematic review’, International Journal of Pediatric Otorhinolaryngology, 138, article 110356. Available at: https://doi.org/10.1016/j.ijporl.2020.110356 UK Haemophilia Centre Doctors’ Organisation (UKHCDO) (n.d.) Haemophilia centres and resources. Available at: https://www.ukhcdo.org/

Tongue tone can be relevant to infant feeding because the tongue needs to maintain an appropriate level of muscular activity while also making coordinated movements for sucking, swallowing and breathing. Effective oral feeding depends on the interaction of these movements rather than on the action of a single muscle, with the tongue working alongside the lips, jaw, palate, pharynx and respiratory system as the infant develops increasingly coordinated feeding skills (Lau, 2015; Lau, 2016; Watson Genna and Sandora, 2017). When reduced tongue tone is observed in an infant, the finding therefore needs to be considered in relation to what the tongue is able to do during feeding. Tongue tone, tongue strength, tongue movement and tongue coordination describe different aspects of function and should not be used interchangeably, particularly when trying to understand why an infant may be experiencing difficulty with feeding. What is tongue tone? Muscle tone is generally described as the tension present within a muscle at rest and the resistance encountered when a muscle is passively stretched. It is influenced by the nervous system and the interaction between neural input and the muscular system, rather than being a simple measure of muscle strength (Ganguly et al., 2021). Muscle tone and muscle strength are consequently different physiological concepts. Strength concerns the force a muscle can voluntarily or reflexively generate, whereas tone relates to the muscle's state and resistance to passive movement. Reduced tone does not therefore necessarily mean that a muscle is weak, just as apparently normal tone does not establish that a muscle has normal functional strength (Ganguly et al., 2021). The tongue is a particularly complex muscular organ. It contains intrinsic and extrinsic muscles arranged in a three-dimensional network, with extensive neuromuscular innervation that permits changes in both tongue shape and position (Mu and Sanders, 2010; Sakamoto, 2018). The intrinsic muscles are contained within the tongue and contribute substantially to changes in its shape, while the extrinsic muscles connect the tongue with surrounding structures and contribute to its movement and positioning (Mu and Sanders, 2010; Sakamoto, 2018). For this reason, when reduced tongue tone is described clinically, it is useful to consider what has actually been observed. An infant may demonstrate reduced resistance to passive movement, reduced ability to maintain a particular tongue position, limited elevation or protrusion, reduced endurance, or difficulty coordinating the tongue with the other movements required for feeding. These findings may have different underlying explanations and should not automatically be interpreted as evidence of a neurological or neuromuscular disorder. Reduced tongue tone (hypotonia) Reduced muscle tone, or hypotonia, describes a reduction in the resistance normally encountered during passive movement and may arise from abnormalities affecting the central or peripheral nervous system, neuromuscular junction or muscle itself (Ganguly et al., 2021). In an infant presenting with feeding difficulty, however, an apparently low-tone tongue does not necessarily indicate generalised hypotonia, as oral feeding skills develop through maturation and experience and differences in oral motor coordination can affect feeding without representing a primary neurological or muscular disorder (Lau, 2016). Where reduced tongue tone is observed, consideration can therefore be given to how the tongue behaves during both rest and active feeding, including its ability to maintain position, elevate, protrude, retract and coordinate with the jaw and other structures involved in sucking and swallowing. Reduced tone may affect the tongue's ability to sustain the movements required for effective feeding, although the clinical significance depends upon the infant's overall functional presentation rather than the appearance of the tongue alone (Watson Genna, 2017). Increased tongue tone (hypertonia) Increased muscle tone, or hypertonia, represents the opposite alteration in tone and describes an abnormal increase in resistance to movement. Hypertonia can arise through a number of neurological mechanisms and should not simply be equated with having a strong or highly active muscle (Ganguly et al., 2021). In the tongue, increased tone may influence the infant's ability to make smooth, graded and appropriately coordinated movements during feeding. As with reduced tone, however, the observation of increased resistance or tension does not by itself establish a diagnosis of hypertonia, and its significance needs to be considered alongside the infant's neurological, oral and feeding presentation. Considering hypotonia and hypertonia together is useful because both represent alterations in muscle tone, but they can affect movement in different ways. Neither finding should be interpreted in isolation from function, and neither should automatically be assumed to explain a feeding difficulty without considering the wider clinical picture. Development and anatomy of the tongue The tongue begins developing during the fourth to fifth weeks of gestation from structures associated with the pharyngeal arches, while the muscular component develops predominantly from occipital somites and subsequently receives its principal motor supply from the hypoglossal nerve (Mu and Sanders, 2010; Thomas et al., 2024). Its anatomy is consequently complex, with intrinsic and extrinsic muscles arranged throughout the tongue rather than functioning as a simple set of isolated muscles. The tongue's neuromuscular organisation allows it to change shape and position rapidly and with considerable precision, which is important for functions including swallowing, respiration and feeding (Mu and Sanders, 2010; Sakamoto, 2018). This developmental and anatomical complexity is relevant when considering tongue tone because an infant's ability to use the tongue effectively depends not simply upon the presence of muscle tissue, but upon the interaction between muscular contraction, neural control, sensory information and the surrounding oral structures. Tongue function during infant feeding Infant feeding involves coordinated patterns of sucking, swallowing and breathing. Sucking provides the initial mechanism for obtaining milk, while swallowing then moves the milk safely from the oral cavity towards the pharynx, with these processes becoming increasingly coordinated as the infant matures (Lau, 2015; Lau, 2016). Watson Genna and Sandora describe sucking and swallowing as closely integrated processes involving coordinated tongue, jaw and oral movements, with the tongue contributing to milk expression and movement within the oral cavity before and during swallowing (Watson Genna and Sandora, 2017). Swallowing itself comprises oral, pharyngeal and oesophageal phases, with the oral phase involving the tongue's preparation and propulsion of the bolus before the pharyngeal swallow is initiated (Watson Genna and Sandora, 2017). The tongue therefore has an important influence on an infant's ability to manage milk within the mouth and to initiate effective swallowing, rather than its role being limited to attachment or milk removal. Lau (2016) similarly describes infant oral feeding as a developing motor skill that depends upon the maturation and coordination of sucking, swallowing and breathing. A difference in tongue tone or movement may consequently have implications for feeding, but the observation itself does not identify the cause. Feeding ability can be influenced by developmental maturity, gestational age, neurological status, oral anatomy, sensory-motor organisation and the mechanics of the feeding method, making a functional feeding assessment more informative than considering tongue tone in isolation (Lau, 2016; Watson Genna and Sandora, 2017). Resting tongue posture The tongue remains under neuromuscular control when an infant is not actively feeding, and its resting position is influenced by the surrounding oral and craniofacial structures as well as by muscular activity (Mu and Sanders, 2010; Sakamoto, 2018). An infant may therefore demonstrate a resting tongue posture that appears low, forward, retracted or otherwise different from that expected for effective oral function. Resting position alone, however, does not establish whether tongue tone is reduced because the position of the tongue results from the interaction between muscular activity, anatomy, sensory and motor control and the surrounding structures. Considering resting posture alongside active movement and feeding function can therefore provide a more meaningful picture than treating a particular resting position as diagnostic in itself. What can contribute to altered tongue tone or function? Altered tongue tone does not have a single cause. Where genuine hypotonia or hypertonia is present, the underlying mechanisms may involve the central or peripheral nervous system, neuromuscular junction or muscle itself, with the clinical presentation depending upon the underlying condition (Ganguly et al., 2021). In an infant presenting with feeding difficulty, however, an apparently low-tone or high-tone tongue does not necessarily indicate a primary neurological or muscular disorder. Infant oral feeding skills develop through maturation and experience, and differences in coordination or oral motor organisation can affect feeding without representing pathological alteration of muscle tone (Lau, 2016). Other factors may therefore need consideration, including prematurity or developmental immaturity, neurological or neuromuscular conditions where clinically indicated, differences in oral anatomy, sensory-motor coordination, fatigue and mechanical restriction of tongue movement. These possibilities should be distinguished from one another rather than being grouped together simply because the tongue appears to have altered tone or movement. A restrictive lingual frenulum is one anatomical factor that may be relevant when there is demonstrable limitation of tongue movement. Tongue function exercises Where reduced tongue tone or impaired tongue function has been identified as contributing to feeding difficulty, targeted tongue exercises may form part of a conservative management approach. The purpose is not simply to exercise the tongue for its own sake, but to encourage more effective muscular recruitment, movement, coordination and endurance in relation to the functional demands of feeding. Watson Genna's work on supporting infant sucking skills includes consideration of tongue exercises within the management of infants with anatomical or functional factors affecting sucking skills, including ankyloglossia (Watson Genna, 2017). The aim of this approach is to improve the infant's ability to use the tongue functionally for feeding, including the movements involved in sucking and swallowing, rather than presenting exercises as a universal treatment for feeding difficulties. Their use is therefore best considered in relation to the findings of the individual feeding assessment and the particular functional difficulty being addressed. Conservative management may be appropriate where the clinical findings indicate that supporting tongue function is a reasonable first approach, including situations in which there is reduced tongue tone or movement but no indication that a surgical procedure is required. Where a restrictive frenulum is also present, conservative management can provide an opportunity to assess whether functional improvement can be achieved without division, while recognising that some infants may continue to have a mechanically restricted tongue despite supportive measures. Tongue-tie, tongue tone and feeding Ankyloglossia refers to a congenital restriction of tongue movement associated with the lingual frenulum, although there remains variation in how ankyloglossia is defined and assessed (Thomas et al., 2024; LeFort et al., 2021). The presence of a lingual frenulum variation does not by itself establish that feeding will be affected, and the American Academy of Pediatrics emphasises the importance of identifying a functional feeding problem rather than diagnosing symptomatic ankyloglossia from anatomy alone (Thomas et al., 2024). A restrictive frenulum can mechanically limit aspects of tongue movement, including elevation and extension, and this provides a plausible explanation for why some infants with ankyloglossia may experience difficulty using the tongue effectively during feeding (Thomas et al., 2024). If movement is restricted, the way in which the tongue is positioned and recruited during sucking and swallowing may also be altered, and this may be observed clinically as reduced functional tongue tone or reduced functional tongue movement. The available evidence does not, however, establish a direct causal pathway in which ankyloglossia causes reduced tongue muscle tone, nor does it establish that division of the frenulum directly increases tongue muscle tone. The more established relationship concerns mechanical restriction of tongue movement and its potential effect on feeding function, while the question of how restriction may influence muscular recruitment and tone requires further research. This distinction is important when considering frenulum division because the evidence for the procedure is primarily concerned with feeding outcomes rather than measurement of tongue muscle tone. The 2017 Cochrane review found that frenotomy reduced maternal nipple pain in the short term but did not consistently demonstrate improvement in objective measures of infant breastfeeding, with the certainty of the evidence limited by small studies and methodological weaknesses (O'Shea et al., 2017). More recent evidence has added to the available literature but has not removed this uncertainty: a 2026 umbrella review identified conflicting findings across systematic reviews, while a 2026 systematic review and meta-analysis of 47 studies found improvements in some feeding-related outcomes but concluded that the overall certainty of evidence supporting frenotomy was very low (da Silva et al., 2026; Dhar et al., 2026). The current evidence therefore supports consideration of frenotomy where a restrictive frenulum is associated with documented functional impairment and conservative measures have not resolved the difficulty, but it does not support presenting division as a treatment for low tongue muscle tone itself. A functional feeding assessment remains important because feeding difficulties can have multiple contributing factors and because the presence of a restrictive frenulum does not necessarily mean that it is the cause of the observed difficulty (Thomas et al., 2024; Dhar et al., 2026). Looking at the whole feeding mechanism Reduced tongue tone is best regarded as one clinical finding within the wider assessment of oral feeding rather than as an explanation for feeding difficulty in itself. The tongue is a complex muscular and sensory structure, and effective feeding depends upon its interaction with the jaw, lips, palate, pharynx and respiratory system as well as upon developing neurological control (Lau, 2016; Mu and Sanders, 2010; Watson Genna and Sandora, 2017). When altered tongue tone is observed, it is therefore useful to consider what movements are affected, whether the finding is consistent across different activities, how it relates to sucking and swallowing, and whether there is an identifiable developmental, neurological, muscular, anatomical or mechanical contributor. Where a restrictive lingual frenulum is present, its significance needs to be considered in relation to demonstrable tongue function rather than anatomy alone. Tongue exercises may provide one conservative management option where reduced tone or function has been identified, with the aim of supporting more effective tongue movement and feeding. Where mechanical restriction remains significant despite appropriate conservative management, frenulum division may be considered when the clinical assessment indicates that the restriction is contributing to the feeding difficulty. Neither approach should be presented as a universal answer to low tongue tone, because the underlying cause and functional presentation will differ between infants. The distinction between anatomy, tone, strength, movement and function is therefore important when considering an infant with feeding difficulty. An evidence-based assessment allows these findings to be considered individually and then brought together to establish the most appropriate explanation and management approach for the feeding dyad. References da Silva, B.V., Barollo, A.V., Sá, N.N.L., Oliveira, L.B. and Sanglard, L.F. (2026) ‘Lingual Frenotomy in Breastfeeding Infants: An Umbrella Review’, International Journal of Paediatric Dentistry, 36(1), pp. 90–104. doi: 10.1111/ipd.70031. 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. Ganguly, J., Kulshreshtha, D., Almotiri, M. and Jog, M. (2021) ‘Muscle Tone Physiology and Abnormalities’, Toxins, 13(4), 282. doi: 10.3390/toxins13040282. Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. doi: 10.1159/000381361. Lau, C. (2016) ‘Development of infant oral feeding skills: what do we know?’, The American Journal of Clinical Nutrition, 103(2), pp. 616S–621S. doi: 10.3945/ajcn.115.109603. LeFort, Y., Evans, A., Arsenault, A., Mazzocchi, A., Dempsey, E., Cormier, C., Cuthbertson, L., Francis, D.O. et al. (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. Mu, L. and Sanders, I. (2010) ‘Human tongue neuroanatomy: nerve supply and motor endplates’, Clinical Anatomy, 23(7), pp. 777–791. doi: 10.1002/ca.21011. 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, 2017(3), CD011065. doi: 10.1002/14651858.CD011065.pub2. Sakamoto, Y. (2018) ‘Structural arrangement of the intrinsic muscles of the tongue and their relationships with the extrinsic muscles’, Surgical and Radiologic Anatomy, 40(6), pp. 681–688. doi: 10.1007/s00276-018-1993-5. Thomas, J., Bunik, M., Holmes, A., Keels, M.A., Poindexter, B., Meyer, A., Gilliland, A. et al. (2024) ‘Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report’, Pediatrics, 154(2), e2024067605. doi: 10.1542/peds.2024-067605. Watson Genna, C. (ed.) (2017) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning. Watson Genna, C. and Sandora, L. (2017) ‘Breastfeeding: normal sucking and swallowing’, in Watson Genna, C. (ed.) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning, pp. 1–42.

Vitamin K is routinely offered to newborn babies in the UK to reduce the risk of vitamin K deficiency bleeding (VKDB), a rare but potentially serious bleeding disorder. For many families, the decision about vitamin K is made shortly before or after birth, at a time when there may already be many new things to consider. Some families accept vitamin K by injection, some choose an oral course, and some decide not to give vitamin K. Families should be given clear information about what vitamin K does, why newborn babies have relatively low levels, what the different routes of administration involve and what options may remain available if the initial decision changes. Vitamin K is not a treatment for feeding difficulties or tongue-tie. Its relevance to feeding is therefore limited, although its status can become important when an invasive procedure such as frenulotomy is being considered because bleeding is a recognised potential complication of the procedure. What is vitamin K? Vitamin K is a fat-soluble vitamin with several functions within the body. One of its most important roles is in normal blood clotting. Vitamin K is required by the liver to produce several vitamin-K-dependent clotting factors, including factors II, VII, IX and X, which are necessary for the blood to form an effective clot. Newborn babies begin life with relatively low vitamin K stores. Only a small amount of vitamin K crosses the placenta, and human milk naturally contains relatively little vitamin K. This means that a newborn has limited reserves during a period when the systems involved in maintaining adequate vitamin K levels are still developing. As infancy progresses, the baby's sources and stores of vitamin K increase. This is a gradual process rather than a particular point at which the risk suddenly disappears, which is one reason why vitamin K deficiency can remain relevant beyond the first few days of life (NICE, 2026a). Vitamin K deficiency matters because insufficient vitamin K can reduce the liver's ability to produce adequate amounts of the clotting factors needed for normal haemostasis. In a baby with significant deficiency, bleeding can therefore occur without an obvious injury to explain it. Why are newborn babies offered vitamin K? Vitamin K deficiency bleeding, or VKDB, is uncommon, but it can be serious and, in some cases, life-threatening. It can occur during the first hours and days after birth or later during infancy. VKDB is generally described according to when it occurs. Early VKDB occurs within the first 24 hours of life, classical VKDB generally occurs during the first week, and late VKDB occurs from around one week until several months of age. Late VKDB is particularly concerning because bleeding can occur internally, including within the brain, and there may not always be an obvious warning before significant illness develops (NICE, 2026a). The purpose of vitamin K prophylaxis is therefore prevention. It does not treat an existing feeding problem, tongue-tie or other newborn condition; it reduces the likelihood that a baby will develop bleeding as a result of vitamin K deficiency. NICE recommends that vitamin K prophylaxis is offered to newborn babies because vitamin K deficiency bleeding, although rare, can have serious consequences (NICE, 2026a). How is vitamin K administered? In the UK, vitamin K can be administered by intramuscular injection or orally. NICE recommends that parents should be offered vitamin K prophylaxis and explains that intramuscular administration is the most effective method. Where parents do not want their baby to receive an injection, oral vitamin K should be offered as an alternative (NICE, 2026a). Vitamin K by injection The intramuscular injection is generally given into the baby's thigh. A single dose provides a reliable source of vitamin K during the period when the baby is most vulnerable to deficiency. As with any injection, there can be brief discomfort and local effects such as soreness or bruising. These considerations can form part of the discussion with families when they are deciding which route they prefer. Vitamin K by mouth Oral vitamin K provides an alternative for families who do not want their baby to receive an intramuscular injection. The important difference is that oral administration involves a course of doses rather than relying on a single injection. The exact preparation and dosing schedule should be provided by the maternity or neonatal service and followed according to the manufacturer's instructions. NICE advises that families choosing oral vitamin K should understand that several doses may be required, including doses after the baby has left hospital (NICE, 2026a). This means that an oral course is dependent on the recommended doses actually being received. If a dose is missed, vomited or otherwise not given, the family should seek advice from the healthcare professional responsible for the baby's care about what should happen next rather than assuming that the course remains complete. The route of administration is also considered in the context of the individual baby. Prematurity, illness and other clinical circumstances may affect which option is most appropriate. What if a family initially declines vitamin K? Parents and legal caregivers should be able to make an informed decision about vitamin K after being given appropriate information about its purpose, benefits and limitations. A decision to decline vitamin K should not prevent a family from accessing other healthcare or from asking questions and revisiting the decision. Some families may initially decline vitamin K but later decide that they would like their baby to receive it. In that situation, the appropriate next step is to contact the maternity service, neonatal team, GP, health visitor or another appropriate NHS healthcare professional so that the baby's age, health, previous doses and the available preparation can be taken into account. There is not one universal catch-up approach that can simply be applied to every baby who initially declined prophylaxis. The appropriate regimen depends on the individual circumstances, so families should obtain advice from the service responsible for the baby's care rather than relying on a general schedule found online. This is an area where informed choice is particularly important. Dr Sara Wickham has written extensively about vitamin K, including the evidence surrounding prophylaxis, the distinction between relative and absolute risk, and what families who decline vitamin K should know (Wickham, 2026a; Wickham, 2026b). Her work provides additional discussion for families who want to explore the evidence and uncertainties surrounding the decision. What if an oral course was started but not completed? An incomplete oral course needs to be distinguished from a completed course of oral prophylaxis. If one or more doses have been missed, the appropriate response depends on the baby's age, the preparation used, which doses were received and the baby's wider health circumstances. Families should therefore contact the relevant maternity, neonatal or medical service for advice. This distinction can become particularly important if the baby subsequently requires an invasive procedure. Knowing that “vitamin K was given” is not necessarily enough information; the route, timing and completion of an oral course may all be relevant when considering the baby's current circumstances. Vitamin K and clinical procedures Vitamin K status can become particularly relevant when an infant is being considered for an invasive or surgical procedure. Frenulotomy involves division of the lingual frenulum and is a regulated surgical procedure in its own right. Although the area being divided is small, tissue containing blood vessels is being cut and bleeding is a recognised potential complication. A small amount of bleeding may occur following frenulotomy and will generally be managed as part of the procedure and its immediate aftercare. More significant bleeding is uncommon, but it is one of the risks that should be considered when assessing whether a procedure is appropriate. For this reason, vitamin K status may form part of the clinical assessment before an elective procedure. This may include establishing whether vitamin K was given, whether it was administered intramuscularly or orally, whether an oral course was completed and whether there are other factors that could affect bleeding risk. The absence of vitamin K prophylaxis does not automatically mean that an elective procedure can never take place. Equally, a clinician or service may determine that it is not appropriate to proceed until the individual bleeding risk has been assessed more fully. This is an important distinction. A decision to postpone or decline an elective procedure because the bleeding risk cannot be adequately assessed is a clinical safety decision. It should not be presented as a judgement about the family for having made a particular decision regarding vitamin K. What else might affect bleeding risk? Vitamin K status is only one part of an assessment. A baby's medical history may identify additional circumstances that warrant consideration before an invasive procedure. These can include prematurity, significant illness, a known liver condition, conditions affecting bile flow or vitamin absorption, unexplained or unusual bruising or bleeding, or a family history of a diagnosed bleeding disorder. The liver is particularly relevant because it is responsible for producing the vitamin-K-dependent clotting factors. Conditions affecting liver function can therefore have implications for haemostasis independently of whether vitamin K prophylaxis was given. Conditions affecting bile flow can also be relevant because vitamin K is fat-soluble and its absorption depends partly on normal fat digestion and bile delivery to the intestine. Persistent pale or unusually light stools, particularly when accompanied by jaundice or dark urine, require medical assessment because they can be signs of cholestasis or another underlying condition. This is not simply a question of whether the baby has “bowel problems”, and such symptoms should not be attributed to vitamin K deficiency without appropriate assessment. Where there is uncertainty about a baby's bleeding risk, medical review may be appropriate. In some circumstances, blood tests assessing clotting may form part of that assessment. The decision to investigate should be based on the individual baby and the clinical question rather than automatically applying the same testing to every baby who has not received vitamin K. A normal screening result also does not exclude every possible bleeding disorder, so investigations should be interpreted alongside the baby's history and clinical presentation. What should families know if vitamin K was declined? Families who have decided not to give vitamin K should know what symptoms require medical attention, because the absence of prophylaxis means the baby remains at risk of VKDB. Unexplained bleeding should be medically assessed rather than assumed to be part of normal newborn care. This may include persistent bleeding from the umbilical area, bleeding from the nose or mouth, blood in the urine, blood in vomit or stools, or unusual bruising. More serious symptoms can include marked pallor, unusual sleepiness, difficulty waking, seizures or other signs that the baby is acutely unwell. Internal bleeding may not always be immediately visible, which is one reason why significant changes in a baby's behaviour or condition should not be dismissed. Families should seek urgent medical attention if their baby appears seriously unwell or develops unexplained bleeding. Vitamin K and feeding Vitamin K is not a treatment for breastfeeding difficulties, bottle-feeding difficulties, milk transfer problems or tongue-tie. There is a difference in vitamin K content between human milk and infant formula, with formula containing added vitamin K. This does not mean that one method of feeding should be considered preferable on the basis of vitamin K. Vitamin K prophylaxis is offered because newborn babies have relatively low vitamin K stores and can develop VKDB irrespective of how their feeding develops. Feeding difficulties should therefore be assessed on their own merits. A baby who is struggling with breastfeeding, bottle feeding, expressing or combination feeding may have a range of contributing factors, and vitamin K status should not be used as an explanation for feeding symptoms. Similarly, vitamin K does not determine whether a baby has a tongue-tie or whether frenulotomy is clinically appropriate. Decisions about tongue-tie should consider function, feeding history, observed feeding where appropriate, growth, comfort, previous support and the individual circumstances of the feeding dyad. Vitamin K, choice and individual assessment The decision about vitamin K belongs within the wider process of informed consent and individualised newborn care. For some families, the decision will be straightforward. Others may want to understand more about the evidence, the difference between injection and oral administration, or what declining prophylaxis means. A family may also make one decision immediately after birth and reconsider it later as circumstances or understanding change. Respecting informed choice does not remove the responsibility of healthcare professionals to explain relevant risks, nor does it require a practitioner undertaking an elective procedure to ignore an unresolved bleeding risk. Where vitamin K has been declined, where an oral course is incomplete, or where records cannot confirm what was administered, the appropriate response before an elective procedure may therefore be an individual assessment of the baby's bleeding risk. Depending on the circumstances, this may involve obtaining further clinical information, seeking medical advice or considering investigations such as coagulation screening. For frenulotomy, this forms only one part of the overall assessment. The reason for considering the procedure, the infant's oral function, feeding circumstances, potential benefits and limitations, alternatives and the family's informed decision all remain relevant. Vitamin K is one part of newborn care, but understanding why it is offered, how it can be administered and what happens when prophylaxis is declined or incomplete allows families and healthcare professionals to approach the subject with greater clarity and without unnecessary assumptions. References National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE. National Institute for Health and Care Excellence (NICE) (2026a) Postnatal care. NICE guideline NG194. London: NICE. National Institute for Health and Care Excellence (NICE) (2026b) Intrapartum care. NICE guideline NG235. 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. Puckett, R.M. and Offringa, M. (2000) 'Prophylactic vitamin K for vitamin K deficiency bleeding in neonates', Cochrane Database of Systematic Reviews, 4, CD002776. Watson, R., McNinch, A., Gillbertson, C. et al. (2011) 'Guidelines on the administration of vitamin K to newborn infants', British Journal of Haematology, 154(1), pp. 8–17. Wickham, S. (2026a) 'Five things parents should know if they decide to decline vitamin K'. Sara Wickham. Wickham, S. (2026b) 'Vitamin K: evidence, risk and informed choice'. Sara Wickham.

Making up infant formula safely involves more than mixing powder and water. Powdered infant formula is not sterile, so the way it is prepared, cooled, stored and given can affect the risk of bacterial contamination (First Steps Nutrition Trust, 2026). For standard powdered infant formula, NHS guidance recommends using freshly boiled water that has been allowed to cool for no more than 30 minutes, so that it remains at least 70°C when the powder is added (NHS, 2026a). The 70°C temperature applies to preparation, not feeding. The hot water is used to reduce the risk from bacteria that may be present in powdered formula. The finished feed must then be cooled before it is offered to the baby because formula that is too hot can cause a burn (NHS, 2026a). Why powdered formula should be made fresh Powdered infant formula should be made up one feed at a time, as it is needed, rather than routinely preparing several bottles in advance and storing them in the fridge (NHS, 2026a; First Steps Nutrition Trust, 2026). Powdered formula is not sterile and bacteria can be introduced through the powder, feeding equipment, hands or preparation surfaces. Once the powder has been mixed with water, bacteria can multiply if the feed is kept for a period of time (First Steps Nutrition Trust, 2026). If feeding away from home, NHS guidance recommends taking the measured formula powder separately, together with an empty sterilised bottle and a full vacuum flask containing freshly boiled water. The feed can then be made up when it is needed (NHS, 2026b). If this method cannot be followed, ready-to-feed liquid formula can be used instead (NHS, 2026b). Powdered formula and ready-to-feed formula Infant formula is available as powdered formula and as ready-to-feed liquid formula. Powdered formula needs to be prepared carefully because it is not sterile. Ready-to-feed liquid formula is already prepared and does not need water or powder to be added (NHS, 2026c). Ready-to-feed formula is sterile until opened. Once opened, it should be refrigerated and used according to the manufacturer's instructions. NHS guidance states that opened liquid formula should be used within 24 hours (NHS, 2026c). This is different from formula left in a bottle after a baby has started drinking. Any formula remaining after a feed should be discarded rather than refrigerated for later use (NHS, 2026a). Ready-to-feed formula does not need to be warmed if a baby is happy to drink it at room temperature. If it is warmed, it should be heated using warm water or a suitable bottle warmer and never in a microwave, which can create hot spots and cause burns (NHS, 2026c). Before making up a powdered formula feed Bottles, teats, caps and other feeding equipment need to be thoroughly cleaned and sterilised before use. Hands and the preparation surface should also be clean (NHS, 2026a; UNICEF UK Baby Friendly Initiative, 2022). For information about cleaning and sterilising feeding equipment, see: How to sterilise feeding equipment If a cold-water sterilising solution has been used, follow the steriliser manufacturer's instructions. NHS guidance advises shaking off excess solution and, where rinsing is required, using cooled boiled water rather than tap water (NHS, 2026a). Why does the water go into the bottle first? The correct amount of water should be measured into the sterilised bottle before the formula powder is added. This is important because adding formula powder changes the final volume of the feed. The powder occupies space within the water and, once dissolved, increases the volume of the prepared feed. Measuring the water first therefore provides the correct starting volume for the manufacturer's formula-to-water ratio. The amount of water and powder varies between products, so always follow the instructions for the particular formula (NHS, 2026a). Many standard powdered formulas use approximately one level scoop for every 30 ml of water, but this is not universal. The manufacturer's instructions take precedence. How to make up a powdered formula feed The following reflects NHS guidance for standard powdered infant formula. Specialist formulas may have different preparation instructions. 1. Use fresh cold tap water. Fill the kettle with at least 1 litre of fresh water from the cold tap. Do not use previously boiled water or artificially softened water (NHS, 2026a; First Steps Nutrition Trust, 2024). 2. Boil the water. Allow the boiled water to cool in the kettle for no more than 30 minutes so that it remains at least 70°C when the powder is added (NHS, 2026a). 3. Clean the preparation area and wash your hands. Clean and disinfect the surface being used before preparing the feed (NHS, 2026a; UNICEF UK Baby Friendly Initiative, 2022). 4. Prepare the sterilised bottle. Keep the teat, cap and other components in a clean place rather than directly on the work surface. 5. Measure the water first. Pour the correct amount of hot water into the bottle and check the level carefully before adding any powder (NHS, 2026a; First Steps Nutrition Trust, 2024). 6. Add the formula powder. Use the scoop supplied with the formula and follow the manufacturer's instructions exactly. Scoops should be level rather than heaped (NHS, 2026a). 7. Mix the feed. Assemble the bottle and shake or mix according to the manufacturer's instructions until the powder has dissolved. 8. Cool the feed. Hold the bottle, with the lid securely in place, under cold running water. A sealed bottle can also be stood in a container of cold water to help it cool (NHS, 2026a). 9. Check the temperature. Place a few drops on the inside of the wrist. The feed should feel warm or cool rather than hot (NHS, 2026a). 10. Give the feed when it is ready. Powdered formula should be prepared fresh rather than routinely prepared in advance (NHS, 2026a). 11. Discard leftovers. Any formula remaining after the baby has started drinking should be thrown away (NHS, 2026a). The UNICEF UK Baby Friendly Initiative Guide to Bottle Feeding also provides guidance on preparing formula and sterilising feeding equipment (UNICEF UK Baby Friendly Initiative, 2022). Why should powdered formula be prepared with water of at least 70°C? Powdered infant formula cannot be assumed to be sterile. Using water at a temperature of at least 70°C when reconstituting powdered formula is intended to reduce the risk from bacteria that may be present in the powder (First Steps Nutrition Trust, 2026). The temperature needs to be considered at the point when the water and powder are combined. Research examining formula preparation in UK homes found that water dispensed by formula preparation machines was frequently below 70°C, potentially allowing bacteria in powdered formula to survive (Grant et al., 2024). The finished feed should then be cooled before feeding. The 70°C preparation temperature and the cooler drinking temperature serve different purposes. Formula preparation machines Formula preparation machines use a different process from the NHS method of preparing powdered formula with freshly boiled water that remains at least 70°C when the powder is added (NHS, 2026a). Some use a fixed-volume "hot shot" before cooler water is added. The amount of hot water therefore represents a different proportion of the feed depending on its size, while the final drinking temperature is not the same as the preparation temperature needed to reduce bacterial risk. The original Perfect Prep was investigated by BBC Watchdog in 2016 after concerns about bacterial contamination, with bacteria found in water from some machines tested. Research published subsequently has also found that formula preparation machines do not consistently deliver water at or above 70°C (Grant et al., 2024). Filters, cleaning and descaling also need consideration. Filter use varies considerably according to how frequently a machine is used and the size of the bottles being prepared. A machine used for around eight feeds a day for a newborn will process considerably more water than one used once a day for a toddler, even though a calendar-based filter replacement period may be similar. Hard-water areas can also result in greater mineral build-up and a greater need for descaling. There have also been reports of black or mould-like material inside some machines. These reports were investigated separately, with the manufacturer stating that the material was carbon residue associated with filtration rather than mould (Sky News, 2017). A preparation machine should therefore not automatically be considered equivalent to the NHS kettle method simply because it produces a bottle quickly at a suitable drinking temperature. Rapid-cooling devices Rapid-cooling devices are designed to cool freshly prepared powdered formula quickly. Current First Steps Nutrition Trust guidance advises against relying on these devices until they have been independently tested and shown to be safe. Its concern is that rapid cooling reduces the time the powdered formula is exposed to heat, potentially allowing bacteria to survive. Additional containers and handling steps can also introduce further opportunities for contamination (First Steps Nutrition Trust, 2026). The current recommendation remains to prepare powdered formula using freshly boiled water that has cooled to no less than 70°C, then cool the prepared bottle under cold running water before feeding (First Steps Nutrition Trust, 2026; NHS, 2026a). A rapid-cooling device should not therefore be treated as a replacement for the hot-water preparation step. What about hot-water or boiling-water taps? Hot-water and boiling-water taps should not automatically be assumed to be equivalent to the NHS kettle method. The important consideration is the temperature of the water when it is combined with the powdered formula. First Steps Nutrition Trust has shown that the temperature of water from a hot tap can fall relatively quickly once it has been transferred into a bottle, particularly with smaller volumes (First Steps Nutrition Trust, 2019). Different taps will also produce different temperatures, so a hot tap cannot simply be assumed to provide water at the temperature required for preparing powdered formula. First Steps Nutrition Trust also advises caution with baby kettles that repeatedly reboil water to maintain temperature, as repeated boiling may concentrate some elements in the water (First Steps Nutrition Trust, 2019). Fresh water and the manufacturer's preparation instructions should always be used. Cooling and checking the finished feed Once the powdered formula has been mixed with the hot water, it needs to be cooled before feeding. The bottle can be held, with the lid securely in place, under cold running water. It can also be stood in a container of cold water to help it cool (NHS, 2026a). Some bottle systems have vents or other openings, so care is needed to ensure that water cannot enter the bottle during cooling. Follow the manufacturer's instructions for the particular feeding equipment. Check the finished feed by placing a few drops on the inside of the wrist. It should feel warm or cool rather than hot (NHS, 2026a). There is no requirement for every baby to drink formula at exactly the same temperature. The important consideration is that the feed is not hot enough to cause a burn. Never microwave infant formula because it can heat unevenly and create hot spots (NHS, 2026a). Making formula away from home Powdered formula should still be prepared fresh when it is needed when feeding away from home. NHS guidance recommends taking a measured amount of formula powder in a clean, dry container, an empty sterilised bottle and a clean vacuum flask containing freshly boiled water. If the flask is full and sealed, the water should remain above 70°C for several hours (NHS, 2026b). The feed can then be prepared when it is needed rather than preparing bottles in advance. If the recommended method cannot be followed, NHS guidance advises using ready-to-feed liquid formula instead (NHS, 2026b). How much formula does a baby need? The amount of formula a baby takes can vary considerably. Babies may want different amounts at different feeds and may feed little and often. Responsive feeding means responding to the baby's feeding cues rather than expecting every feed to be the same size or requiring a bottle to be finished (NHS, 2026d; UNICEF UK Baby Friendly Initiative, 2022). First Steps Nutrition Trust provides approximate guidance on the amounts of infant formula that may be offered at different stages. These figures are based on average energy requirements and average infant weights and are not targets for individual babies (First Steps Nutrition Trust, 2020). | Age | Approximate feeds | Approximate amount per feed | Approximate total per day | |---|---:|---:|---:| | Up to 2 weeks | 7–8 feeds | 60–70 ml | 420–560 ml | | 2–8 weeks | 6–7 feeds | 75–105 ml | 450–735 ml | | 2–3 months (9–14 weeks) | 5–6 feeds | 105–180 ml | 525–1,080 ml | | 3–5 months (15–25 weeks) | 5 feeds | 180–210 ml | 900–1,050 ml | | About 6 months (26 weeks) | 4 feeds | 210–240 ml | 840–960 ml | | 7–9 months | Breakfast, lunch, tea and before bed | About 150 ml | About 600 ml | | 10–12 months | Breakfast, tea and before bed | About 100 ml, 100 ml and 200 ml | About 400 ml | These are approximate figures rather than required volumes. Babies vary in appetite and feeding patterns, particularly during the early weeks, and some may need smaller feeds more frequently (First Steps Nutrition Trust, 2020). For information about responding to a baby's cues during bottle feeding, see Responsive Bottle Feeding. Bottle position and support can also affect how comfortably a baby feeds. See Bottle Feeding Positions. Different types of formula may have different preparation instructions There are several types of infant formula, and the preparation instructions are not necessarily identical. First infant formula is suitable from birth and can remain the main formula throughout the first year. Follow-on formula is not required at six months (NHS, 2026c). Specialist formulas can have different preparation instructions. Anti-reflux formulas, for example, contain thickening ingredients and some products require a period of standing after preparation because the feed thickens. Some manufacturers also give different instructions about the temperature of the water used to prepare these products (NHS, 2026c). This means that the instructions for the particular formula being used should always be followed rather than assuming that the standard preparation method applies to every product. Specialist formulas used under medical supervision should be prepared according to the instructions supplied with the product or by the relevant healthcare professional. The key distinction: preparation temperature and feeding temperature The temperature of formula matters at two different points for different reasons. During preparation, water at or above 70°C is used with powdered formula to reduce the risk from bacteria that may be present in the powder. Before feeding, the prepared formula must be cooled so that it is not hot enough to burn the baby's mouth. A feed therefore needs to be hot enough during preparation for the safety process to be effective, but cool enough afterwards for safe feeding. Further information The UNICEF UK Baby Friendly Initiative Guide to Bottle Feeding provides guidance on preparing infant formula and sterilising feeding equipment (UNICEF UK Baby Friendly Initiative, 2022). First Steps Nutrition Trust: Making infant milk safely provides further information about powdered infant formula, preparation machines and alternative preparation methods (First Steps Nutrition Trust, 2026). References First Steps Nutrition Trust (2019) Making up bottles of infant formula from hot taps and baby kettles. London: First Steps Nutrition Trust. First Steps Nutrition Trust (2020) Infant milks: A simple guide to infant formula, follow-on formula and other infant milks. London: First Steps Nutrition Trust. First Steps Nutrition Trust (2024) Infant milks: A simple guide to infant formula, follow-on formula and other infant milks. London: First Steps Nutrition Trust. First Steps Nutrition Trust (2026) Making infant milk safely. London: First Steps Nutrition Trust. Available at: https://www.firststepsnutrition.org/making-infant-milk-safely Grant, A., Jones, S., Sibson, V., Ellis, R., Dolling, A., McNamara, T., Cooper, J., Dvorak, S., Breward, S., Buchanan, P., Yhnell, E. and Brown, A. (2024) ‘The safety of at home powdered infant formula preparation: A community science project’, Maternal & Child Nutrition, 20(1), e13567. doi:10.1111/mcn.13567. NHS (2026a) How to make up a bottle feed. NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/how-to-make-up-a-feed/ NHS (2026b) Formula milk: common questions. NHS. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/formula-milk-questions/ NHS (2026c) Types of formula milk. NHS. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/types-of-formula/ NHS (2026d) How to bottle feed. NHS. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/ Sky News (2017) ‘Tommee Tippee investigates reports of “mould” in formula machines’, 15 March. Available at: https://news.sky.com/story/tommee-tippee-investigates-reports-of-mould-in-formula-machines-10802939 UNICEF UK Baby Friendly Initiative (2022) Guide to bottle feeding: How to prepare infant formula and sterilise bottles. UNICEF UK Baby Friendly Initiative. Available at: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/bottle-feeding-resources/guide-to-bottle-feeding/ ```

When milk production appears lower than expected, it is easy to start looking for something that might increase it. Galactogogues are medicines, herbs or other substances used with the intention of increasing milk production, but the evidence for their effectiveness is mixed. For some families, a galactogogue may have a place within an individualised feeding plan. For others, it may add cost, side effects or complexity without addressing the reason milk production appears to be low. Before considering one, it is useful to establish whether milk production is actually lower than expected and, if so, what may be contributing to this. What are galactogogues? Galactogogues are substances used with the intention of increasing milk production. They include prescription medicines as well as herbal and food-based products. Medicines that have been studied in lactation include domperidone and metoclopramide. Herbal and food-based products marketed for milk production may contain ingredients such as fenugreek, fennel, milk thistle, moringa or shatavari, either individually or in combination. The existence of a product marketed as a galactogogue does not establish that it works. The more useful questions are whether it has been shown to increase milk production, in which circumstances, by how much, and whether any potential benefit outweighs its risks (Brodribb, 2018; Foong et al., 2020). Is milk production actually low? One of the first questions is whether there is evidence of low milk production rather than a change in how the breasts feel or how feeding looks. Milk production changes considerably during the early weeks after birth. Initially, lactation is largely under endocrine control, with hormonal changes following birth playing an important role in establishing milk production. As lactation becomes established, control becomes increasingly autocrine. Milk production is then more closely regulated within the breast according to milk removal and local mechanisms within the mammary gland (De Coopman, 1993; Knight, Peaker and Wilde, 1998; Wilde et al., 1998). As this transition occurs, the initial fullness of the breasts commonly reduces and the breasts may feel much softer between feeds. This is an expected change in established lactation. Soft breasts at this stage do not, by themselves, mean that milk production has fallen or that there is not enough milk. After the early weeks, an infant's growth, hydration and overall feeding picture are much more useful indicators of milk intake than breast fullness alone. NHS guidance identifies weight gain, wet nappies, swallowing during feeds and other aspects of feeding as useful indicators that an infant is receiving enough milk (NHS, 2026). Frequent feeding, periods when an infant is unsettled or obtaining a small volume when expressing can also be interpreted as signs of low supply when they may have other explanations. Expressed milk volume is not a direct measurement of total milk production. Pump fit and settings, timing, breast fullness, milk ejection and an individual's response to expressing can all affect the amount collected during a particular session. My articles Increasing Breast Milk Production and How to Express Breastmilk look at milk production and expressing in more detail. A proper assessment considers the wider feeding picture, including infant growth and hydration, feeding frequency, milk transfer, maternal health, birth and postpartum history and expressing practices where relevant (Brodribb, 2018; Foong et al., 2020). Positioning and attachment can also affect how comfortably and effectively milk is removed. My articles Breastfeeding latch and positioning and How to Improve Infant Latch: Practical Breastfeeding Support explore these areas further. If expressing is part of the feeding plan, pump fit can also be relevant. Breast Pump Flange Fitting: Finding What Works for You considers how flange fit can affect comfort and milk removal. Infant oral function may also be relevant in some feeding situations, but an anatomical finding does not, by itself, establish that it is the cause of reduced milk transfer or milk production. Function needs to be considered alongside the whole feeding picture. My article Breastfeeding problems caused by tongue-tie? explores why feeding difficulties need to be considered more broadly than the appearance of the lingual frenulum. What does the evidence actually show? The evidence for galactogogues is limited and does not support a universal recommendation for their use. A Cochrane review of oral galactogogues in mothers of healthy term infants included 41 studies involving 3,005 mothers. The studies varied considerably in the interventions used, participant characteristics and outcome measures. There was low-certainty evidence that pharmacological galactogogues may increase milk volume, while evidence for natural galactogogues was very uncertain (Foong et al., 2020). This does not mean that an individual cannot experience an increase in milk production after using a galactogogue. It means that the available evidence does not allow us to predict reliably who will benefit, how much benefit can be expected or whether an observed change was caused by the galactogogue itself. The Academy of Breastfeeding Medicine advises that potentially modifiable causes of low milk production are assessed before considering a galactogogue, rather than using medication or supplements as the first response to the concern (Brodribb, 2018). Does the preparation matter? Yes. A herb is not a single standardised dose simply because it has the same name on the packet. A tea, capsule, powder, tincture, extract, cookie or other food containing an herb can provide very different amounts of its active constituents. A teabag and a concentrated extract are not necessarily equivalent. This means that evidence from a study using one particular preparation cannot automatically be applied to a different commercial product containing the same herb. The same applies to products containing several ingredients. If a study examines a particular combination, its findings cannot automatically be transferred to another tea, supplement or food containing some of the same ingredients. This is one reason the evidence for commercial lactation products can be difficult to interpret. A product may contain an ingredient that has been studied without the product itself having been studied. A randomised controlled trial of commercially available lactation cookies containing oatmeal, brewer's yeast, flaxseed and fenugreek found no significant difference in milk production between the intervention and control cookies. The study also found no significant difference in perceived insufficient milk or breastfeeding self-efficacy (Palacios et al., 2023). The presence of ingredients traditionally or commercially described as galactagogues does not, by itself, establish that a particular food will increase milk production. What about herbal galactogogues? Herbal products are sometimes perceived as a gentler alternative to medicines because they are described as natural. Natural does not necessarily mean effective, free from side effects or suitable for everyone. Fenugreek, fennel, milk thistle, moringa and shatavari are among the herbs that have been studied or used in relation to milk production, but the amount and quality of evidence varies considerably. The Cochrane review found substantial variation between studies and uncertainty around the effects of natural galactogogues (Foong et al., 2020). Herbal products can also cause side effects or interact with medicines. Products may contain several ingredients, and the amount of an active constituent can vary between preparations. There is also a difference between traditional use and evidence of clinical effectiveness. A herb may have been used for generations for a particular purpose without there being good-quality clinical evidence showing that it produces that effect. That does not make traditional knowledge irrelevant. It does mean that it should not be presented as equivalent to evidence from well-designed clinical research. Can herbs reduce milk production too? This is another part of the discussion that is sometimes overlooked. Some herbs and herbal preparations are traditionally used with the intention of reducing milk production, particularly during weaning or when someone is experiencing oversupply. Sage and peppermint are two commonly discussed examples. The evidence for these effects is limited. LactMed reports that sage is traditionally used to reduce lactation and that peppermint has also been used to suppress milk production, but clinical evidence demonstrating these effects in breastfeeding women is lacking. For peppermint, milk-suppressing effects have been demonstrated in vitro and in animals with high doses, but it is not known whether typical human intake would have the same effect (National Library of Medicine, 2025a; 2025b). The important point is that herbal preparations can have different intended effects depending on the herb, preparation and circumstances. “Herbal” does not automatically mean “milk increasing”. If the aim is to reduce or stop breastfeeding, my article Stopping Breastfeeding looks at the gradual changes involved in reducing milk removal and managing the transition. What about domperidone? Domperidone is an anti-sickness medicine that can also increase prolactin and has been used off-label to support milk production. It is not licensed in the UK specifically for increasing milk supply. The Specialist Pharmacy Service suggests that domperidone can be considered for low milk supply after a thorough assessment and once non-medical measures have been tried. Its guidance also notes that most of the evidence comes from mothers expressing milk for preterm infants, with less evidence in mothers feeding healthy term infants (Specialist Pharmacy Service, 2024). Some specialist lactation guidance has described using doses higher than those generally used in current UK practice, including in circumstances such as delayed onset of lactogenesis. These approaches should not be interpreted as general dosing recommendations. Any use of domperidone should be discussed with the prescriber responsible for the individual (Newman, 2005). Cardiac safety also needs to be considered in context. The evidence of increased cardiac risk comes largely from studies in older adults, rather than healthy lactating women. For example, one major study had a mean age of 79.4 years, while evidence in postpartum women remains limited (Johannes et al., 2010; Ou et al., 2021). If domperidone has been used for a period of time, stopping also needs consideration. Some lactation guidance describes gradual reduction rather than simply stopping, particularly after longer-term use. Any change in treatment should be planned with the prescriber rather than made independently (Newman, 2005; The Breastfeeding Network, 2026). What about metoclopramide? Metoclopramide has also been studied as a galactogogue, but evidence of benefit is inconsistent. A systematic review and meta-analysis of eight trials involving 342 lactating women found that metoclopramide increased prolactin concentrations but did not increase milk volume compared with control treatment (Nik Hazlina Nik Hussain et al., 2021). Metoclopramide can also cause adverse effects, including neurological effects and psychological side effects. The Academy of Breastfeeding Medicine therefore advises consideration of potential adverse effects, contraindications and interactions before a galactogogue is used (Brodribb, 2018). The wider evidence does not establish that increasing prolactin will necessarily produce a clinically meaningful increase in milk production for everyone. Milk production is influenced by milk removal as well as hormonal responses, so a higher prolactin level is not, by itself, a guarantee of more milk (Specialist Pharmacy Service, 2024). Why assessment comes before a galactogogue A galactogogue cannot reliably compensate for milk that is not being removed effectively. If milk removal is being limited by ineffective milk transfer, infrequent milk removal, pain, unsuitable expressing equipment or another modifiable factor, addressing that issue may be more important than adding a product (Brodribb, 2018; Foong et al., 2020). For some feeding dyads, positioning and attachment may be relevant. For others, the issue may involve milk transfer, infant oral function, maternal health, breast surgery, medication, hormonal factors or the way expressing is being used. My article When feeding doesn't feel right: Looking beyond tongue-tie considers some of the wider factors that can contribute to feeding difficulties. If the concern is expressed milk volume, it is also worth considering whether the pump, flange fit, expressing frequency and reason for expressing have been assessed before assuming that milk production itself is low. More expressing is not automatically better. If an infant is already removing milk effectively, repeatedly adding extra pumping sessions can sometimes create an oversupply rather than solve the original concern. My article How to Express Breastmilk discusses the different reasons for expressing and why the approach needs to reflect what someone is trying to achieve. How might a proportionate decision be made? If a galactogogue is being considered, the starting point is not necessarily which product to choose. It is what the family is hoping to achieve. The goal might be to increase direct feeding, increase expressed milk, make combination feeding more sustainable or reduce the need for supplementation. It is then useful to consider: Is milk production actually lower than expected? Is milk being removed frequently and effectively? Are there maternal or infant factors affecting milk production or transfer? Are positioning, attachment or expressing practices contributing? Is there a medical reason for reduced production that needs assessment? What evidence supports the proposed galactogogue? What preparation is actually being considered? Could any other medicines, herbs or supplements be affecting milk production? How will any benefit be assessed? When will the plan be reviewed? What will happen if there is no meaningful benefit? For some families, useful measures may include infant growth and hydration. For someone expressing, changes in milk volume over a defined period may be useful. For others, the most important outcome may be a feeding plan that is more comfortable or sustainable. A defined review is particularly useful. If something is being used with the intention of increasing milk production, there should be a point at which its effect is considered rather than continuing indefinitely without evidence of benefit. There is no single right response to concerns about milk supply Concerns about milk production can be difficult, particularly when feeding has already involved pain, supplementation, expressing or previous challenges. Using a galactogogue does not mean that someone has failed to feed their baby, and choosing not to use one does not mean that they have failed to try hard enough. The evidence supports a measured approach: establish what is happening with milk production and milk transfer, consider modifiable factors, understand the evidence and potential risks associated with any proposed galactogogue, and agree how the outcome will be reviewed. If there are concerns about milk production, feeding or milk transfer, an individual assessment can help identify what may be contributing. This may include support from an appropriately qualified infant feeding specialist, such as an IBCLC, alongside medical assessment where indicated. My article When feeding doesn't feel right: Looking beyond tongue-tie considers the wider feeding picture, while Breastfeeding latch and positioning, How to Improve Infant Latch: Practical Breastfeeding Support, How to Express Breastmilk and Breast Pump Flange Fitting: Finding What Works for You explore specific areas in more detail. Sometimes a galactogogue may have a place. In other circumstances, the more useful intervention may be addressing milk removal, feeding technique, expressing equipment or an underlying maternal or infant factor — or establishing that milk production is not actually lower than expected. 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. doi: 10.1089/bfm.2018.29092.wjb. De Coopman, J. (1993) ‘Breastfeeding after pituitary resection: support for a theory of autocrine control of milk supply?’, Journal of Human Lactation, 9(1), pp. 35–40. doi: 10.1177/089033449300900129. Foong, S.C., Tan, M.L., Foong, W.C., Marasco, L.A., Ho, J.J. and Ong, J.H. (2020) ‘Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants’, Cochrane Database of Systematic Reviews, 2020(5), CD011505. doi: 10.1002/14651858.CD011505.pub2. Johannes, C.B., Varas-Lorenzo, C., McQuay, L.J., Midkiff, K.D. and Fife, D. (2010) ‘Risk of serious ventricular arrhythmia and sudden cardiac death in a cohort of users of domperidone: a nested case-control study’, Pharmacoepidemiology and Drug Safety, 19(9), pp. 881–888. doi: 10.1002/pds.2016. 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. doi: 10.1530/ror.0.0030104. National Library of Medicine (2025a) ‘Peppermint’, Drugs and Lactation Database (LactMed®). Bethesda, MD: National Institute of Child Health and Human Development. Last revision 15 June 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501851/ National Library of Medicine (2025b) ‘Sage’, Drugs and Lactation Database (LactMed®). Bethesda, MD: National Institute of Child Health and Human Development. Last revision 15 July 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501816/ Newman, J. (2005) ‘Domperidone’, Handout #19a, January 2005. Available at: https://breastfeedingmadesimple.com/wp-content/uploads/2016/02/newman_Domperidone1-January2005.pdf Nik Hazlina Nik Hussain, N.H., Mohd Noor, N., Ismail, S.B., Zainuddin, N.A. and Sulaiman, Z. (2021) ‘Metoclopramide for milk production in lactating women: a systematic review and meta-analysis’, Korean Journal of Family Medicine, 42(6), pp. 453–463. doi: 10.4082/kjfm.20.0238. NHS (2026) ‘Breastfeeding: is my baby getting enough milk?’, NHS. Page last reviewed 30 April 2026. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding-problems/enough-milk/ Ou, L.B., Moriello, C., Douros, A. and Filion, K.B. (2021) ‘Domperidone and the risks of sudden cardiac death and ventricular arrhythmia: a systematic review and meta-analysis of observational studies’, British Journal of Clinical Pharmacology, 87(10), pp. 3649–3658. doi: 10.1111/bcp.14737. Palacios, A.M., Cardel, M.I., Parker, E., Dickinson, S., Houin, V.R., Young, B. and Allison, D.B. (2023) ‘Effectiveness of lactation cookies on human milk production rates: a randomized controlled trial’, The American Journal of Clinical Nutrition, 117(5), pp. 1035–1042. doi: 10.1016/j.ajcnut.2023.03.010. Specialist Pharmacy Service (2024) ‘Using domperidone for low milk supply’. Published 21 June 2024. Available at: https://www.sps.nhs.uk/articles/using-domperidone-for-low-milk-supply/ The Breastfeeding Network (2026) ‘Domperidone and breastfeeding’, Drugs in Breastmilk Information. Last full review September 2019; last amended May 2026. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/domperidone/ Wilde, C.J., Addey, C.V., Bryson, J.M., Finch, L.M., Knight, C.H. and Peaker, M. (1998) ‘Autocrine regulation of milk secretion’, Biochemical Society Symposium, 63, pp. 81–90.

A submucous cleft palate can be particularly difficult to identify because the surface of the palate may appear intact. The underlying muscles may not have formed or joined in the usual way, even though there is no obvious opening in the roof of the mouth. This article explains how a submucous cleft can be missed, what signs may raise the possibility, how it can affect feeding and speech, what treatment may be considered and how to seek a review if you are unsure. What is a submucous cleft palate? The term cleft describes a gap or separation that occurs when the developing lip and/or palate do not join completely during pregnancy (CLAPA, n.d.). There are several different terms used when describing cleft lip and palate: Cleft lip – a gap or split in the upper lip. It may affect one side (unilateral) or both sides (bilateral), and may be complete or incomplete. The gum or alveolus may also be affected. Cleft palate – a gap in the roof of the mouth. It may affect the soft palate alone or extend into the hard palate. Cleft lip and palate – both the upper lip and palate are affected. Where the lip is affected, this may be unilateral or bilateral. Isolated cleft lip – a cleft lip without a cleft palate. Isolated cleft palate – a cleft palate without a cleft lip. Submucous cleft palate – a cleft affecting the underlying muscles of the palate while the oral lining remains intact, meaning there may be no obvious opening in the roof of the mouth. Occult submucous cleft palate – a more subtle form in which some of the usual visible features of a submucous cleft may not be present. Terms such as unilateral, bilateral, complete, incomplete and isolated describe the pattern or extent of a cleft rather than being separate types of cleft (CLAPA, n.d.). A submucous cleft is therefore not simply a small or minor cleft. The underlying structures of the palate may be affected even though the surface appears intact, which can make identification more difficult (CLAPA, n.d.; Cambridge University Hospitals NHS Foundation Trust, 2023). How can a cleft palate be missed? Cleft lip is often identified during the routine antenatal ultrasound scan at around 20 weeks, although not every cleft lip is visible. An isolated cleft palate is much more difficult to identify on an ultrasound scan because the gap is inside the mouth and may not be visible (NHS, n.d.; CLAPA, n.d.). If a cleft palate has not been identified antenatally, the palate should be examined after birth as part of the newborn examination. However, seeing the whole palate can be challenging, particularly when examining the soft palate. Submucous clefts can be even more difficult to recognise because the oral lining may appear intact. Some may remain undetected for months or years and may only become apparent when feeding, speech, hearing or other concerns develop. The Royal College of Paediatrics and Child Health recommends that the hard and soft palate are visually inspected using a torch and an appropriate method of depressing the tongue so that the whole palate can be seen. This applies not only to the newborn examination but also to the 6–8 week examination and to infants whose palate is examined at any other time by a healthcare professional (RCPCH, 2025). The Cleft Palate Assessment Poster produced for healthcare professionals also highlights the importance of appropriate palate assessment across the different professional groups involved in infant care and feeding (Cleft Nursing Clinical Excellence Network, 2024, updated 2025). If the whole palate cannot be seen, that limitation is important. An inability to see the palate properly should not automatically be taken as evidence that the palate is normal. What might a submucous cleft palate look like? A traditional description of a submucous cleft palate includes three features: a bifid or split uvula a zona pellucida, where the middle part of the soft palate appears thin or translucent a notch in the back edge of the hard palate. Not every child with a submucous cleft will have all three features. In an occult submucous cleft, these visible features may be absent altogether (Kaplan, 1975; Reiter et al., 2011). A bifid uvula on its own does not necessarily mean that a child has a submucous cleft palate. It can occur without an associated palatal problem, although it can also be associated with a submucous cleft (Cambridge University Hospitals NHS Foundation Trust, 2023). The appearance of the palate is therefore only part of the assessment. Palatal function, feeding history, speech and other clinical findings may also be relevant. What feeding signs may raise concern? The signs associated with a submucous cleft palate are not specific to a cleft and can occur for many other reasons. However, a combination of difficulties may indicate that the palate needs closer assessment. Possible feeding signs include: milk coming through the nose during or after feeds clicking during feeding continued difficulty attaching at the breast difficulty maintaining suction tiring during feeds prolonged feeds faltering growth a bifid uvula increased work of breathing associated with feeding difficulties. These are among the signs highlighted in the Cleft Palate Identification Poster (Cleft Nursing Clinical Excellence Network, 2024, updated 2025). A palatal difference can affect the ability to create an effective seal and may affect milk transfer (Cambridge University Hospitals NHS Foundation Trust, 2023; Moss, Jones and Pigott, 1990). However, a baby with a submucous cleft palate may breastfeed or bottle-feed effectively and may have no obvious feeding difficulties. Equally, the absence of milk coming through the nose does not exclude a submucous cleft. Why might milk come through my baby's nose? The palate separates the mouth from the nasal cavity. During feeding, the baby needs to coordinate sucking, swallowing and breathing while creating an effective seal within the mouth. Where there is a structural or functional difference affecting the palate, milk can sometimes enter the nasal cavity and come through one or both nostrils. Milk coming through the nose does not, by itself, indicate a cleft palate. Nasal milk can occur for other reasons, particularly while a young baby is developing feeding coordination. However, persistent or repeated nasal regurgitation, particularly when it occurs alongside other feeding difficulties or an unusual appearance of the palate, warrants further assessment. What happens as my child gets older? A submucous cleft palate may become apparent during infancy, but some children have few or no obvious symptoms initially. Speech concerns may become more apparent as speech develops. The soft palate needs to move effectively to separate the mouth from the nose during speech. Where the palate does not achieve effective velopharyngeal closure, this can contribute to increased nasal resonance or a nasal quality to the voice and nasal air emission. Some children may also have difficulty developing particular speech sounds or develop compensatory speech patterns. These findings are not specific to submucous cleft palate and should not be used on their own to make a diagnosis. Where there are concerns about hypernasality, nasal air emission or speech sound development, a speech and language assessment may form part of a wider cleft assessment. Hearing can also be relevant. Children with cleft palate can have an increased risk of middle-ear problems because the muscles of the palate are involved in Eustachian tube function (Reiter et al., 2011; NHS, n.d.). A submucous cleft does not inevitably cause feeding, speech or hearing difficulties. Some children require monitoring only, while others may need additional assessment or treatment depending on how the palate is functioning. What if the palate looks normal? An intact-looking palate does not exclude a submucous cleft palate. A quick look at the front of the mouth is not sufficient to assess the whole palate. The hard and soft palate need to be visualised properly. The RCPCH best practice guide recommends using a torch and an appropriate method of depressing the tongue to visualise the whole palate, including the full soft palate (RCPCH, 2025). If the whole palate cannot be seen, this should be recognised as a limitation of the examination rather than assumed to mean that the palate is normal. This is also relevant when assessing feeding difficulties where a tongue-tie or restrictive lingual frenulum is being considered. Looking only at the lingual frenulum and tongue movement may overlook other anatomical or functional factors that could be contributing to feeding. Could a submucous cleft be mistaken for a tongue-tie restriction? There can be an overlap between some of the feeding signs associated with a submucous cleft palate and those associated with a restrictive lingual frenulum. Clicking, difficulty maintaining suction, difficulty attaching, prolonged feeds and difficulties with milk transfer can have many possible causes. A restrictive lingual frenulum may be one contributing factor, but it should not automatically be assumed to explain every feeding difficulty. There is also a recognised genetic association between cleft palate and ankyloglossia. Research into the TBX22 gene identified X-linked cleft palate with ankyloglossia, with the associated clinical features including cleft palate, submucous cleft palate, bifid uvula and ankyloglossia in some affected individuals (Braybrook et al., 2001; Braybrook et al., 2002). TBX22 variants have also been identified in a small proportion of apparently nonsyndromic cleft palate cases (Pauws, Moore and Stanier, 2009). This does not mean that every child with a cleft palate will have a tongue-tie, or that a tongue-tie indicates a genetic cause. Rather, it demonstrates that the development of the palate and tongue can be linked in some genetic conditions. Where a baby has a cleft lip or palate alongside a restrictive lingual frenulum, assessment should therefore consider the wider oral anatomy and overall clinical picture. A multidisciplinary team (MDT) approach can be particularly important where cleft palate is suspected or confirmed, bringing together relevant aspects of feeding, oral anatomy, speech and language, hearing and wider clinical needs rather than considering the lingual frenulum in isolation. If division of a lingual frenulum is being considered in a baby with a cleft palate, specialist consideration is required. It may need to take place within a hospital or other specialist setting rather than a routine infant tongue-tie setting. The appropriate NHS specialist team should determine whether division is indicated and where it should take place. A comprehensive tongue-tie assessment should consider the wider oral anatomy, tongue movement and feeding function. The aim is not to attribute feeding difficulties to one anatomical feature automatically, but to understand the feeding dyad and identify whether further assessment or support is appropriate. What treatment is available for a submucous cleft palate? Treatment depends on the type of cleft, how the palate is functioning and whether it is causing difficulties. A submucous cleft palate does not automatically mean that surgery is required. Some children are monitored by their Cleft Team without needing an operation. Where there are feeding, speech, hearing or other functional concerns, assessment may involve several members of the cleft multidisciplinary team, including cleft specialist nurses, paediatrics, speech and language therapy, audiology, dental or orthodontic services and specialist surgeons where appropriate. For babies experiencing feeding difficulties, specialist feeding support can be provided while the palate is being assessed. This may include consideration of positioning, attachment, feeding efficiency and, where necessary, alternative or specialised feeding equipment. The priority is that the baby receives sufficient milk safely and effectively (NHS, n.d.). Speech and language assessment may be appropriate where there are concerns about speech development, resonance or velopharyngeal function. Where there are significant functional problems associated with the palate, surgery may be considered. This is an individual decision based on functional assessment and the wider clinical picture rather than the appearance of the palate alone. If surgery is being considered, the Cleft Team can discuss the potential benefits, risks and timing with the family or caregivers. The approach is not the same for every child. The important consideration is therefore not simply whether a submucous cleft is present, but whether it is affecting function and what support or treatment is appropriate. What should you do if you are unsure? If you are unsure, ask for a review. There is no need to be certain that a submucous cleft is present before asking for further assessment. If the palate has not been fully visualised, an unusual palatal feature has been noticed, or feeding difficulties raise concerns about palatal function, further assessment may be appropriate. Submucous clefts can be subtle and not every child will have the classical visible features. Where a cleft palate is identified or suspected, assessment by the appropriate NHS Cleft Team allows feeding, hearing, speech and development to be considered alongside the anatomy of the palate (NHS, n.d.; RCPCH, 2025). For families and caregivers, asking for a review does not mean that a cleft will necessarily be found. It means that the possibility can be considered rather than overlooked. What about feeding support while assessment is taking place? Families and caregivers should not necessarily have to wait for a definitive diagnosis before receiving feeding support. Assessment can consider attachment, milk transfer, feeding duration, coordination, growth and hydration, as well as the experience of the feeding dyad. Support can be provided whether the baby is breastfeeding, bottle-feeding, receiving expressed milk, formula feeding or combination feeding. Some babies with a submucous cleft feed effectively without specialised equipment, while others may need additional or alternative feeding methods. The priorities are safe and effective feeding, adequate milk intake, growth and the wellbeing of the baby and feeding dyad while any further assessment is arranged. Where can families find support? A baby or child with a diagnosed cleft lip or palate will normally be referred to an NHS specialist Cleft Team for multidisciplinary assessment, treatment and ongoing care (NHS, n.d.; CLAPA, n.d.). If a cleft has not been diagnosed but there are concerns about a possible submucous cleft palate, families or caregivers can speak to their GP, health visitor or another healthcare professional involved in the baby's care and ask for an assessment or referral. If the baby or child is already known to a Cleft Team, the team can be contacted using its usual contact details if new concerns about feeding, speech, hearing or palatal function arise. It may not be necessary to wait for a routine appointment. The NHS provides information about specialist cleft services, and the appropriate healthcare professional can advise on the relevant service for the family's area. CLAPA, the Cleft Lip and Palate Association, provides information and support for families affected by cleft lip and palate, including information about postnatal diagnosis and submucous cleft palate. It can also provide opportunities to connect with other families. This support does not replace specialist clinical assessment and care. If you are unsure whether your baby's feeding difficulties could be related to a palatal difference, ask for a review rather than trying to diagnose the problem yourself. References Braybrook, C., Doudney, K., Marcano, A.C.B., Arnason, A., Bjartmar, C., Patton, M.A., Goodfellow, P.J., Moore, G.E. and Stanier, P. (2001) ‘The T-box transcription factor gene TBX22 is mutated in X-linked cleft palate and ankyloglossia’, Nature Genetics, 29(2), pp. 179–183. Braybrook, C., Lisgo, S., Scambler, P. and Stanier, P. (2002) ‘Craniofacial expression of human and murine TBX22 correlates with the cleft palate and ankyloglossia phenotype observed in CPX patients’, Human Molecular Genetics, 11(22), pp. 2793–2804. Cambridge University Hospitals NHS Foundation Trust (2023) Bifid Uvula and Submucous Cleft Palate. Cleft Nursing Clinical Excellence Network (2024) Cleft Palate Identification. Updated with CRANE data June 2025. CLAPA (n.d.) Postnatal diagnosis. CLAPA (n.d.) What is cleft lip and palate? Kaplan, E.N. (1975) ‘The occult submucous cleft palate’, The Cleft Palate Journal, 12, pp. 356–368. Moss, A.L.H., Jones, K. and Pigott, R.W. (1990) ‘Submucous cleft palate: a review’, British Journal of Plastic Surgery, 43(3), pp. 273–278. NHS (n.d.) Cleft lip and palate. NHS (n.d.) Cleft lip and palate – Treatment. Pauws, E., Moore, G.E. and Stanier, P. (2009) ‘A functional haplotype variant in the TBX22 promoter is associated with cleft palate and ankyloglossia’, Human Mutation, 30(9), pp. 1260–1266. Reiter, R., Brosch, S., Wefel, H., Schlöndorff, G. and Pickhard, A. (2011) ‘The submucous cleft palate: an overview’, International Journal of Pediatric Otorhinolaryngology, 75(4), pp. 500–505. Royal College of Paediatrics and Child Health (2025) Palate examination: Identification of cleft palate in the newborn and infant. Best practice guide.

Nipple pain and breast pain are common reasons for seeking help with breastfeeding. The pain may feel burning, stabbing, throbbing or tingling, and it can occur during a feed, immediately afterwards or between feeds. If nipple pain is particularly strong after feeding, when the nipple is exposed to cold air, or when the nipple changes colour, you may come across the term nipple vasospasm. Raynaud’s phenomenon is one possible cause of nipple vasospasm, but it is not the only one. Understanding the difference can help identify what may be contributing to the pain and what support may be useful. For more about some of the reasons breastfeeding can become uncomfortable, see When Breastfeeding Doesn’t Feel Right. What is Raynaud’s phenomenon? Raynaud’s phenomenon is a condition in which small blood vessels temporarily constrict, reducing blood flow to the affected area. It most commonly affects the fingers and toes, but the nipples can also be affected (The Breastfeeding Network, 2019). Cold is a common trigger. During breastfeeding, the nipple can be particularly exposed to changes in temperature because it may be uncovered and wet immediately after a feed. Moving from the warmth of the breast or baby’s mouth into cooler air can trigger blood-vessel constriction in some people. The nipple may become white or pale as blood flow reduces, followed by blue or purple colouring as oxygen levels in the tissue change, and then red or pink as blood flow returns. These colour changes are sometimes described as a triphasic response, although not everyone experiences all three stages. Pain can be severe and may be described as burning, throbbing, stabbing or shooting. It may occur immediately after a feed or continue for some time afterwards. Symptoms can affect one or both nipples. A history of Raynaud’s phenomenon elsewhere in the body, circulation problems or migraines may provide additional clues, although these are not required for nipple symptoms to occur (The Breastfeeding Network, 2019; GP Infant Feeding Network, n.d.). What is nipple vasospasm? Nipple vasospasm describes temporary constriction of the blood vessels supplying the nipple. It can cause significant pain and may be associated with visible changes in nipple colour. Nipple vasospasm does not necessarily mean that someone has Raynaud’s phenomenon. A nipple can become compressed during breastfeeding, particularly when attachment is shallow or the nipple is being squashed between the baby’s tongue and the roof of the mouth. The resulting vascular response can cause the nipple to blanch and become painful after the feed. In this situation, vasospasm can be a response to mechanical compression rather than Raynaud’s phenomenon (The Breastfeeding Network, n.d.). Improving positioning and attachment may resolve compression-related nipple vasospasm, whereas Raynaud’s phenomenon may continue despite comfortable attachment. For more information about attachment, see Latching Your Baby. Raynaud’s phenomenon and nipple vasospasm: what is the difference? The terms are sometimes used interchangeably, but they describe different things. Nipple vasospasm describes what is happening to the blood vessels: they temporarily constrict, reducing blood flow to the nipple. Raynaud’s phenomenon describes a vascular condition in which blood vessels constrict in response to triggers such as cold or emotional stress. When Raynaud’s affects the nipple, it can cause nipple vasospasm. Nipple vasospasm can therefore occur without Raynaud’s phenomenon. It can be a normal vascular response to nipple compression caused by a poor or shallow latch. A white nipple immediately after a feed can be a useful clinical clue towards vasospasm, but it does not confirm a diagnosis of Raynaud’s phenomenon. Recognising a possible pattern The timing of the pain can provide useful information. Raynaud’s-related nipple vasospasm may be more likely when: pain begins or becomes significantly worse immediately after feeding the nipple is exposed to cold air after a feed the nipple is still wet after feeding when exposed to the cooler environment the nipple changes colour, particularly becoming white, purple or red warmth relieves the pain symptoms are triggered by cold at other times symptoms occur even when positioning and attachment appear comfortable there is a personal history of Raynaud’s phenomenon or other circulation problems. However, colour changes are not always obvious. In a study of 22 breastfeeding women diagnosed with Raynaud’s phenomenon of the nipple, only 14 had notable nipple colour changes recorded (Barrett et al., 2013). Colour changes may also be more difficult to recognise on some skin tones. The absence of an obvious colour change therefore does not necessarily exclude nipple vasospasm. Nipple compression as a cause of vasospasm Mechanical compression is an important cause of nipple vasospasm. If the nipple is being compressed during breastfeeding, blood flow through the small vessels can temporarily reduce. The nipple may then appear white and become painful when the baby comes off the breast. Suboptimal positioning or attachment, or a baby repeatedly compressing the nipple during feeding, can contribute to this pattern (GP Infant Feeding Network, n.d.; The Breastfeeding Network, n.d.). If the latch feels pinchy or painful, changing position or attachment may help. Your baby’s body position, the way they approach the breast and the depth of attachment can all influence how much pressure is placed on the nipple. Latching Your Baby and When Breastfeeding Doesn’t Feel Right may be useful alongside individual breastfeeding support. Skilled breastfeeding support, including support from an IBCLC, can be useful when the cause is unclear or when changes to positioning and attachment have not resolved the symptoms. You can read more about the role of an IBCLC in What is an IBCLC?. Other factors that may contribute Cold is particularly relevant to Raynaud’s phenomenon, but other factors can also influence vascular constriction. Caffeine and nicotine can contribute to vasoconstriction and may make symptoms worse for some people. The Breastfeeding Network recommends reducing caffeine and stopping smoking as part of managing Raynaud’s symptoms (The Breastfeeding Network, 2019). Stress may also affect vascular responses and can contribute to symptoms, although it is not necessary for Raynaud’s phenomenon to occur. Pumping can also produce nipple pain and vascular symptoms. Excessive suction, an unsuitable flange size or prolonged pumping can cause nipple compression or trauma. If symptoms occur primarily following pumping, the pump settings and flange fit may therefore be worth reviewing. What can help at home? Keeping the nipple and breast warm is one of the simplest measures that may help reduce vasospasm. You could try: keeping the breasts covered and warm after feeds avoiding sudden exposure to cold air immediately after feeding covering the nipple as soon as the feed finishes adding an extra layer of clothing around the breasts using sheepskin inserts or another insulating layer inside the bra applying a warm compress or other heat-retaining product after feeding reducing caffeine if it appears to worsen symptoms avoiding smoking or nicotine. The Breastfeeding Network also recommends gently applying warm oil to the nipple after feeding. If using oil for warmth or comfort, it should be comfortably warm rather than hot, and care should be taken to avoid burns to already painful or sensitive skin (The Breastfeeding Network, 2019). Warmth should be soothing rather than intense. Heating pads, reusable heat packs and similar products can cause burns if they are too hot or left against the skin for too long. When should you speak to a breastfeeding specialist? If nipple pain continues despite comfortable positioning and attachment, or if there is a recurring pattern of pain after feeds with colour changes or cold sensitivity, further clinical assessment may be useful. An IBCLC or other appropriately trained breastfeeding professional can assess feeding position, attachment, nipple compression and the circumstances in which the pain occurs. This can help distinguish mechanical causes of nipple vasospasm from a pattern that may be consistent with Raynaud’s phenomenon. It can also be helpful to describe exactly when the pain starts, how long it lasts, whether warmth helps and whether the nipple changes colour. Taking a photograph of the nipple colour change, if it occurs and you are comfortable doing so, may also provide useful information during an assessment. Could medication help? If symptoms are persistent or severe and Raynaud’s phenomenon is suspected, a GP may consider medication to reduce vascular constriction. Nifedipine is a calcium-channel blocker that has been used to treat Raynaud’s phenomenon affecting the nipple. Research involving breastfeeding women has reported improvement or resolution of nipple pain in many of those who were able to tolerate nifedipine treatment (Barrett et al., 2013). A GP may consider a slow-release or modified-release nifedipine preparation. Modified-release preparations are available with different dosing schedules, including preparations that are taken twice daily, so the exact formulation and dose need to be determined by the prescriber. Information about medicines and breastfeeding is available through the Breastfeeding Network Drugs in Breastmilk service, which provides evidence-based information about medication use during breastfeeding (The Breastfeeding Network, n.d.). The GP Infant Feeding Network information on pain when breastfeeding also includes information about assessment and management of nipple vasospasm and Raynaud’s phenomenon. References Barrett, M.E., Heller, M.M., Fullerton Stone, H., Murase, J.E. and Mancini, A.J. (2013) ‘Raynaud phenomenon of the nipple in breastfeeding mothers: an underrecognized cause of nipple pain’, JAMA Dermatology, 149(3), pp. 300–306. Available at: https://jamanetwork.com/journals/jamadermatology/fullarticle/1485351 GP Infant Feeding Network (n.d.) ‘Pain when breastfeeding’. Available at: https://gpifn.org.uk/pain-when-breastfeeding/ The Breastfeeding Network (2019) ‘Raynaud’s Phenomenon in Breastfeeding Mothers’. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/raynauds/ The Breastfeeding Network (n.d.) ‘Drugs in Breastmilk’. Available at: https://www.breastfeedingnetwork.org.uk/drugs-in-breastmilk/ The Breastfeeding Network (n.d.) ‘Pain: If breastfeeding hurts’. Available at: https://www.breastfeedingnetwork.org.uk/breastfeeding-information/problems-with-breastfeeding/pain-if-breastfeeding-hurts/

Swallowing is an essential part of milk transfer during infant feeding. Sucking draws milk into the mouth, but getting milk into the mouth is only the beginning of the process. The milk needs to be contained and organised as a bolus, moved towards the back of the mouth, and then transferred onwards through the pharynx and oesophagus towards the stomach. The tongue plays an important role in moving the milk posteriorly. As the milk bolus reaches the oropharyngeal area, sensory input contributes to the initiation of the pharyngeal swallow. The pharyngeal phase then propels the milk through the pharynx and into the oesophagus, followed by oesophageal transport towards the stomach (Lau, 2015; Jadcherla et al., 2017). Swallowing is often described using a four-phase model: oral preparatory, oral transit or propulsive, pharyngeal and oesophageal phases. However, infant feeding literature also commonly describes three broader phases — oral, pharyngeal and oesophageal — with the oral phase incorporating the preparation and propulsion of the milk bolus. The terminology therefore varies between sources, but the underlying sequence remains the same: milk enters the mouth, is organised and moved posteriorly, the swallow is initiated, and the milk is transported onwards (Lau, 2015; Jadcherla et al., 2017). During a feed, swallowing is coordinated with sucking and breathing. This coordination develops as an infant matures and can vary according to the baby's developmental stage, the feeding method and the rate at which milk is available (Mizuno, Ueda and Takeuchi, 2002; Mizuno and Ueda, 2003). Although the swallow itself occurs internally, some of the associated movement can be observed externally. Learning what to look for can therefore help families recognise when active swallowing is taking place during a breast or bottle feed. Recognising a swallow during a feed One of the most useful places to observe swallowing is underneath your baby's chin, towards the upper front of the neck. During a swallow, this area draws inwards and deepens. Breathing movements can also be seen in the neck, but these are further down the neck, so they can be distinguished from the movement associated with swallowing. The external movement does not mean that the swallow itself can be seen directly. The swallow takes place within the mouth and throat, while the movement underneath the chin provides an observable indication that the swallowing mechanism is occurring. Ultrasound studies have been used to examine what is happening internally during breastfeeding. Geddes et al. (2010), for example, used ultrasound imaging to observe milk movement during infant swallowing and demonstrated the relationship between swallowing, milk movement and respiratory pauses. This provides a useful reminder that the movement seen from outside the baby's body is only one visible part of a much more complex physiological process. Swallowing may also be audible, although an audible sound is not essential for a swallow to be occurring. A clear swallowing sound can accompany milk being transferred, but sounds heard during a feed need to be interpreted carefully. Noisy sucking, clicking or repeated gulping can also occur when air is being drawn into the mouth, particularly where the seal between the baby's mouth and the breast or teat is not being maintained. In that situation, the sound should not automatically be interpreted as evidence of effective milk transfer. Where audible air intake is accompanied by clicking, milk leakage, loss of suction or other signs of difficulty maintaining attachment, the wider feeding pattern is more informative than the sound alone. For a visual demonstration of what swallowing can look like at the breast, Lucy Webber IBCLC's video *Recognising when a baby is swallowing effectively at the breast* shows the external signs to look for (Webber, 2026). What can swallowing look like during a feed? There is considerable variation in how sucking, swallowing and breathing are coordinated between babies and between different stages of the same feed. There is therefore no single pattern that every baby should demonstrate. During active feeding, sucking draws milk into the mouth and swallowing moves that milk onwards. A baby does not necessarily need to swallow after every suck. The number of sucking movements between swallows can change according to milk flow, the baby's developmental maturity and what is happening during the feed. At the breast, some babies may begin with a period of quicker sucking associated with stimulating milk ejection before settling into a pattern in which sucking and swallowing become more closely associated with active milk transfer. NHS guidance describes feeds as often beginning with a few rapid sucks before progressing to longer, rhythmic sucks and swallows, with occasional pauses (NHS, 2026). Breastfeeding also serves purposes beyond nutritional intake. Babies may breastfeed for comfort, reassurance, closeness and regulation as well as to obtain milk. This means that a baby may move between periods of active milk transfer and periods of lighter or more comfort-focused sucking during the same breastfeeding episode. The presence of fewer visible swallows during such a period does not necessarily indicate a problem with milk transfer, because the purpose of the sucking may have changed. The overall pattern of the feed, the baby's coordination and the presence of sustained active milk transfer provide more useful information than whether an individual feed follows a particular sequence. Rhythm, milk flow and swallowing Observing swallowing over a meaningful period of active feeding is generally more informative than focusing on one isolated swallow. The rhythm of swallowing can change as milk flow changes, and this can happen naturally during both breast and bottle feeding. When milk is readily available and flowing more quickly, swallows may occur closer together because the baby has milk available to move onwards. As the flow slows, there may be more sucking movements between individual swallows. The resulting pattern may therefore become less frequent without this necessarily indicating a problem. At the breast, milk flow is dynamic rather than constant. It can change during milk ejection and as the feed progresses, so the spacing between visible swallows may change accordingly. A baby may therefore have periods in which swallowing is frequent and obvious, followed by periods in which more sucking occurs between swallows. Bottle feeding also involves changes in milk flow. Teat flow, bottle angle and the way the feed is offered can all influence how quickly milk reaches the baby's mouth. This is one reason that the baby's swallowing pattern should be considered alongside the way the bottle is being offered rather than interpreted in isolation. Counting visible swallows can sometimes be a useful observational aid. It can help a family or practitioner notice whether swallowing is occurring regularly during active feeding and whether the rhythm changes as milk flow changes. However, there is no prescribed number of visible swallows that a baby needs to achieve during a feed, and counting cannot determine the exact volume of milk transferred. What can swallowing tell you about milk transfer? Seeing repeated swallowing during a period of active feeding provides evidence that milk is being transferred beyond the mouth. It is therefore one useful part of observing milk transfer, but it cannot be used to calculate exactly how much milk a baby has taken. The amount of milk transferred depends on more than the number of visible swallows. The volume of milk contained in each bolus can vary, as can milk flow, sucking patterns and the baby's ability to maintain feeding over time. Two babies may therefore show different swallowing patterns while both are transferring milk effectively. Swallowing is best considered alongside the wider picture of feeding. This can include the baby's alertness and stamina, their ability to remain coordinated during the feed, whether they appear settled and satisfied afterwards, urine output, growth and other indicators of adequate milk intake. For further information about observing milk transfer during feeds, see Signs of Poor Milk Transfer in Your Baby at Feeds. Breastfeeding and swallowing At the breast, the pattern of sucking and swallowing can change considerably during a single breastfeeding episode. A period of rapid sucking may occur as the baby stimulates milk ejection, followed by a more sustained pattern of active sucking and swallowing once milk is flowing more readily. Ultrasound research has demonstrated the relationship between tongue movement, intra-oral vacuum and milk transfer during breastfeeding (Geddes, Kent, Mitoulas and Hartmann, 2008). Further ultrasound work has allowed researchers to observe the movement of milk during swallowing itself, providing information about the internal sequence that cannot be determined from external observation alone (Geddes et al., 2010). As milk flow changes, the visible rhythm of swallowing may change too. A baby may swallow frequently when milk is flowing readily and then have longer intervals between swallows when the flow becomes slower. It is also important to consider what the baby is using the breast for at that point in the feed. Breastfeeding is not exclusively about nutritional intake. A baby may continue to suckle for comfort or reassurance after active milk transfer has reduced, and the pattern of sucking and swallowing will consequently change. Periods of lighter sucking with fewer visible swallows can therefore occur within a breastfeeding episode without necessarily representing ineffective feeding. The observation is therefore not simply whether a swallow can be seen at one particular moment, but whether swallowing is occurring during periods of active milk transfer and how the baby's overall feeding pattern develops throughout the feed. Bottle feeding and swallowing Bottle feeding also requires coordination between sucking, swallowing and breathing. A 1:1:1 suck–swallow–breathe pattern can occur for some babies and at some stages of a feed, but it is not a universal requirement for effective bottle feeding. Other babies may take several sucks before swallowing, followed by a breath or pause. This is where paced bottle feeding can be particularly relevant. Paced feeding does not aim to make every feed follow a particular suck–swallow–breathe ratio. Instead, it can give the baby greater opportunity to regulate the rate of milk flow and take pauses according to their own feeding pattern. NHS guidance recommends keeping the bottle almost horizontal, allowing the baby to control the pace of the feed and providing opportunities for breaks when the baby shows cues that they need one (NHS, 2026). The baby's pauses can therefore form part of the feeding pattern rather than being something that needs to be eliminated. A baby may pause to breathe, rest or regulate the amount of milk entering the mouth before returning to active sucking and swallowing. Following these cues can help the rate of milk flow fit more closely with the baby's ability to coordinate feeding. The rate of milk flow can also influence the spacing between visible swallows. With a faster flow, milk may reach the mouth more readily and swallows may occur closer together. With a slower flow, more sucking may occur between swallows. Bottle position and feeding technique can influence this flow, which is why paced and responsive bottle feeding consider both the baby's cues and the way the bottle is presented (NHS, 2026). More information about paced bottle feeding and ways of supporting a responsive feeding rhythm can be found in How to Pace Bottle Feeds: A Calm, Practical Guide. When feeding may need further assessment Occasional changes in feeding rhythm are not, by themselves, evidence of a swallowing problem. However, persistent difficulties with coordination or signs that a baby is struggling to manage milk flow may warrant further assessment. Concerns can include repeated coughing, choking or spluttering during feeds, changes in colour, difficulty coordinating breathing with feeding, marked fatigue, frequent loss of milk from the mouth, or an inability to sustain effective feeding. A baby who repeatedly stops feeding because they appear unable to manage the flow of milk may also benefit from closer observation. These signs can have many possible causes, and swallowing should not be considered in isolation. A feeding assessment may consider the baby's oral movements, sucking pattern, breathing, milk flow, positioning, stamina and overall feeding behaviour alongside growth and other indicators of adequate intake. Recognising swallowing is therefore one part of observing infant feeding rather than a standalone test. Looking at the movement underneath the chin and upper front of the neck, and considering its frequency and rhythm across a substantial period of active feeding, can provide useful information about when swallowing is taking place. That observation becomes more meaningful when considered alongside the wider pattern of the feed and the baby's overall wellbeing. References Geddes, D.T., Chadwick, L.M., Kent, J.C., Garbin, C.P. and Hartmann, P.E. (2010) ‘Ultrasound imaging of infant swallowing during breast-feeding’, Dysphagia, 25(3), pp. 183–191. Available at: https://pubmed.ncbi.nlm.nih.gov/19626366/ 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. Available at: https://pubmed.ncbi.nlm.nih.gov/18262736/ Jadcherla, S.R. et al. (2017) ‘Advances with neonatal aerodigestive science in the pursuit of safe swallowing in infants: invited review’, Dysphagia, 32(1), pp. 15–26. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5303645/ Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4530609/ 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. Available at: https://pubmed.ncbi.nlm.nih.gov/11803176/ Mizuno, K. and Ueda, A. (2003) ‘The maturation and coordination of sucking, swallowing, and respiration in preterm infants’, The Journal of Pediatrics, 142(1), pp. 36–40. Available at: https://pubmed.ncbi.nlm.nih.gov/12520252/ NHS (2026) ‘Bottle feeding your baby’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/ NHS (2026) ‘Bottle feeding your baby: Feeding on demand’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/feeding-on-demand/ Webber, L. (2026) ‘Recognising when a baby is swallowing effectively at the breast’, YouTube, 25 January. Available at: https://www.youtube.com/watch?v=AjCd3wqMmwM

A newborn baby's skull is designed to be adaptable. Rather than being one solid, fused structure, it is made up of several bones separated by flexible sutures, with larger membranous areas called fontanelles between some of the bones. These are the areas commonly known as a baby's “soft spots”. This arrangement allows the skull to accommodate the forces of birth while also providing space for the rapidly growing brain (Lipsett, Reddy and Steanson, 2023; Di Ieva et al., 2017). The skull remains relatively malleable during infancy because the cranial bones and sutures continue to develop as the brain grows. The sutures provide areas where growth and adjustment can occur, while the fontanelles provide flexible spaces between the developing bones (Di Ieva et al., 2017; Shah et al., 2016). Because the skull is adaptable during this stage of life, its shape can be influenced by several different factors. These include the baby's position in the uterus, the amount of space available before birth, the relationship between the baby's head and the maternal pelvis, the way labour progresses, whether birth is vaginal or by caesarean section, whether forceps or vacuum assistance is used, and how the baby's head is positioned after birth. Some changes in shape are temporary and settle naturally. Others may persist or develop further during the early months of life, resulting in patterns such as plagiocephaly, brachycephaly or dolichocephaly. There are also less common causes of unusual skull shape, including craniosynostosis, where one or more skull sutures fuse prematurely (Dias and Samson, 2017; Kapp-Simon et al., 2021). Head shape is therefore more than an issue of appearance. Where there is marked asymmetry, there can also be differences in the relationship between the skull, face, jaw and neck. As these structures are involved in feeding, it is reasonable to consider head and body alignment as part of the wider feeding picture, while recognising that skull shape alone cannot tell us whether a baby will experience feeding difficulties. The flexible newborn skull A newborn baby's skull consists of several bones rather than a single solid structure. Fibrous sutures separate the bones, while the fontanelles are membranous areas where several bones meet. These areas are commonly described as a baby's “soft spots” (Lipsett, Reddy and Steanson, 2023; Di Ieva et al., 2017). The sutures and fontanelles have important functions beyond simply making the skull flexible. They allow movement between the bones during birth and provide room for the skull to enlarge as the brain grows. The sutures therefore remain important sites of cranial growth throughout infancy and childhood (Di Ieva et al., 2017; Shah et al., 2016). This flexibility is particularly relevant during birth because the baby's head has to negotiate the maternal pelvis and birth canal. The skull bones can move relative to one another and overlap to some degree, allowing the shape of the head to adapt to the mechanical forces acting upon it (Dias and Samson, 2017; Lipsett, Reddy and Steanson, 2023). This temporary change in shape is known as birth moulding. Influences on head shape before birth The mechanical influences on a baby's head begin before labour. As pregnancy progresses, the baby occupies an increasingly confined space within the uterus. The baby's presentation and position, the available space and the way the head and body are positioned can all influence the forces acting on the developing musculoskeletal system. Some babies remain in a relatively fixed position for a considerable period. Research in otherwise healthy newborns has identified associations between prolonged intrauterine positioning and asymmetries involving the head, neck and face, including torticollis and craniofacial asymmetry (Stellwagen et al., 2008). Breech presentation also creates a different mechanical environment from a head-first presentation. Depending on the baby's position and how long that position is maintained, particular patterns of elongation or deformation can develop. Dolichocephaly, for example, can be associated with prolonged breech positioning as well as prematurity (Dias and Samson, 2017). The maternal pelvis also forms part of this mechanical environment. During a vaginal birth, the baby's head has to rotate and descend through the available pelvic space, so the dimensions and shape of the pelvis, the baby's position and the mechanics of labour all contribute to the forces experienced by the head (Dias and Samson, 2017). None of these factors determines a baby's eventual head shape on its own. The mechanical environment is continually changing, and babies respond differently to the forces involved. Birth moulding during vaginal delivery During a vaginal birth, the baby's head is exposed to pressure from the surrounding soft tissues and the bony structures of the birth canal. The skull bones can move and overlap at the sutures, allowing the head to adapt as it descends and rotates through the pelvis (Dias and Samson, 2017; Lipsett, Reddy and Steanson, 2023). This can result in a head that looks elongated, narrow or almost cone-shaped immediately after birth. The appearance can be particularly pronounced where there has been considerable moulding, but it does not necessarily represent the baby's eventual skull shape. The amount of moulding is influenced by the baby's presentation and position, the relationship between the baby's head and the pelvis, and the mechanics of the individual birth. A prolonged labour can involve sustained pressure, but a rapid vaginal delivery can also expose the baby's head to relatively sudden mechanical forces as it descends quickly through the birth canal. A quick birth therefore does not necessarily mean there will be little moulding. Birth-related swelling can also alter the appearance of a newborn's head. Caput succedaneum, for example, is soft-tissue swelling associated with pressure during labour and usually settles as the early postnatal period progresses. Cephalohaematoma can also affect the appearance of the head following birth (Dias and Samson, 2017). The important distinction is that temporary moulding following birth is part of the normal adaptability of the newborn skull. It should not automatically be interpreted as a structural abnormality. Caesarean and instrumental births Caesarean birth generally involves less passage of the baby's head through the birth canal, so the pattern of moulding can differ from that seen following a vaginal birth. However, caesarean birth does not mean that a baby's head will necessarily be perfectly round. Head dimensions can change during the first days of life following both caesarean and vaginal birth (Souza, Ross and Milner, 1976). Instrumental vaginal birth can introduce additional mechanical forces. Forceps and vacuum extraction are associated with different patterns of scalp and cranial findings, including bruising, swelling, moulding, caput and cephalohaematoma (Moczygemba et al., 2004). The wider circumstances of birth can therefore be more informative than simply describing the birth as vaginal, caesarean or instrumental. The baby's presentation, position, speed of descent, duration and mechanics of labour, and any assistance used all form part of the history. Research in newborns has also identified associations between birth trauma and cranial and mandibular asymmetry, while longer second stages and forceps birth were associated with some measures of facial asymmetry (Stellwagen et al., 2008). What happens to head shape after birth? The skull remains adaptable after birth, although the mechanical environment changes considerably. Instead of being influenced primarily by the uterus and birth canal, the baby's head is now affected by gravity, movement, head-turning preferences and the surfaces against which the head rests. A baby who consistently turns towards one side may repeatedly place pressure on the same region of the skull. Restricted neck movement or torticollis can contribute to this preference. Reduced movement and prolonged positioning can also contribute to positional cranial deformation (Bialocerkowski, Vladusic and Wei Ng, 2008; Zhang et al., 2024). Research has identified several factors associated with deformational plagiocephaly, including a persistent head-position preference, reduced tummy time and particular sleeping or positioning patterns, although individual studies do not establish that any one factor will inevitably result in skull asymmetry (Zhang et al., 2024). This means that a baby may have a head shape that reflects influences from before birth, the birth itself, and the weeks or months that follow. The shape seen later in infancy does not necessarily tell us which period contributed most to the asymmetry. Plagiocephaly, brachycephaly and elongated head shapes Several different terms are used to describe infant skull shape, and distinguishing between them is important because they do not all have the same underlying cause. Plagiocephaly Plagiocephaly describes an asymmetrical skull shape. In positional plagiocephaly, this commonly involves flattening towards one side of the back of the head. The asymmetry may also involve the forehead, ears or face because changes in one part of the skull can alter the orientation of neighbouring structures (Dias and Samson, 2017). Positional plagiocephaly is associated with factors including head-position preference, restricted neck movement and positional forces after birth (Bialocerkowski, Vladusic and Wei Ng, 2008; Zhang et al., 2024). Brachycephaly Brachycephaly describes a relatively broad and short head shape, often associated with flattening across the back of the skull. Where pressure is distributed across the back of the head, rather than being concentrated predominantly on one side, the resulting shape can become broader and shorter. Deformational brachycephaly is generally related to external mechanical forces rather than premature fusion of a skull suture (Dias and Samson, 2017). Dolichocephaly and elongated head shapes Dolichocephaly describes a relatively long and narrow head shape. It can occur in association with prematurity and prolonged breech positioning, among other mechanical influences (Dias and Samson, 2017). A long or narrow head immediately following a vaginal birth can also simply reflect birth moulding. The distinction is important because a temporarily elongated newborn head is not automatically evidence of a pathological skull shape. Scaphocephaly Scaphocephaly is another term used for a long, narrow or boat-shaped skull, but it needs to be used carefully. The term is commonly associated with sagittal craniosynostosis, in which the sagittal suture fuses prematurely and restricts growth across that suture. A long head following normal birth moulding or positional forces is not necessarily scaphocephaly in this pathological sense (Dias and Samson, 2017; Wilkie, Johnson and Wall, 2017). Other skull shapes Other characteristic skull shapes can occur, including trigonocephaly and patterns associated with other forms of craniosynostosis. Craniosynostosis is fundamentally different from positional skull deformation because one or more sutures have fused prematurely, restricting growth across the affected suture and producing compensatory changes elsewhere in the skull (Kapp-Simon et al., 2021; Wilkie, Johnson and Wall, 2017). This is why an unusual skull shape that does not fit the expected pattern of birth moulding or positional deformation warrants appropriate medical assessment. The relationship between skull shape and feeding The possible relationship between skull shape and feeding is not simply about whether a baby's head looks symmetrical. The skull, cranial base, face, temporomandibular joints, mandible, neck and spine all contribute to the physical organisation of feeding. The infant needs to bring these structures into a position that allows the mouth to approach the breast or teat while coordinating sucking, swallowing and breathing. Where there is significant cranial asymmetry, the relationship between the skull base, temporomandibular joints and mandible may also be asymmetrical. Research involving infants with deformational posterior plagiocephaly has identified anterior displacement of the temporomandibular joint on the affected side together with apparent rotation of the mandible towards that side (St John et al., 2002). Other research has similarly identified differences in mandibular and temporomandibular joint relationships in infants with different patterns of plagiocephaly (D'Heilly et al., 2007). These findings do not demonstrate that plagiocephaly causes feeding problems, nor do they mean that an infant with plagiocephaly has a temporomandibular joint disorder. They do, however, provide an anatomical reason to consider the relationship between skull shape, jaw position and feeding mechanics when an individual baby is experiencing difficulties. Breastfeeding itself involves coordinated movements of the tongue, lips, mandible and surrounding oral structures, alongside the wider postural and respiratory organisation of the infant (Paglia, 2026). This makes it more useful to consider the whole feeding mechanism than to look at skull shape in isolation. The jaw, neck and spine are part of the same feeding picture Feeding does not take place through the mouth alone. The head is supported by the neck, which connects with the spine, trunk and pelvis. The position of these areas can influence the way the infant brings their mouth towards the breast or teat and the freedom they have to make the movements needed for attachment and feeding. This is particularly relevant where there is torticollis or another positional asymmetry. Clinical literature has described associations between torticollis, craniofacial and spinal asymmetry and breastfeeding difficulties, with positioning adaptations and physical therapy sometimes forming part of management (Genna, 2015). Research into effective breastfeeding has also identified aspects of infant positioning and latching, including allowing the baby's head to remain free of restriction, as relevant elements of effective feeding (2025). The intention is not to place a baby into one rigid “perfect” position. Rather, the baby's body needs enough support to remain comfortable and organised while still allowing the head to move freely, extend towards the breast or teat, open the mouth and establish the attachment. How feeding may look when alignment is different Where head, neck, spinal and jaw alignment are contributing to feeding mechanics, the signs can be subtle and may not be present at every feed. A baby may consistently prefer turning their head in one direction, find one breastfeeding position more comfortable than another, or appear less settled when feeding from the opposite side. Some infants with mandibular asymmetry have been described as having difficulties maintaining an effective latch or seal, with head-turning preference and torticollis also appearing in clinical case reports of breastfeeding difficulties (Wall and Glass, 2006). The same principles of alignment and movement apply to bottle feeding. The baby's body position, head and neck position, bottle angle, teat characteristics and milk flow can all influence how comfortably sucking, swallowing and breathing are coordinated. A difference between feeding positions can therefore be useful information. If a baby consistently feeds more effectively in one position, observing what changes between the two positions can sometimes provide more information than looking at head shape alone. Feeding position as part of the wider assessment There is no single feeding position that works for every baby. For breastfeeding, the relationship between the baby's body and the feeding parent's body, the direction from which the baby approaches the breast, the freedom of the head and neck, the latch and the baby's ability to maintain a comfortable attachment all form part of the feeding picture. NHS guidance similarly describes the importance of the baby's ear, shoulder and hip being aligned and of allowing the baby's head to tip back rather than holding the back of the head in a way that restricts movement (NHS, 2025). For bottle feeding, positioning, pacing, teat flow and the way the bottle is offered similarly influence how easily a baby can coordinate sucking, swallowing and breathing. Further information on breastfeeding positions, breastfeeding latch, bottle feeding positions and paced bottle feeding is available from D-Restricted Ltd®: Breastfeeding positions Breastfeeding latch Bottle feeding positions Paced bottle feeding These aspects can be considered alongside the baby's head, neck, spine and body alignment rather than using skull shape as an explanation for feeding difficulties in isolation. When head shape needs medical assessment Most positional skull-shape changes are considered benign and many become less noticeable as babies grow, develop stronger head control and become more mobile. Positional plagiocephaly is common, and its prevalence tends to decrease as children grow (Bialocerkowski, Vladusic and Wei Ng, 2008). There are nevertheless situations where an unusual head shape warrants further assessment. These include a shape that appears unusual from birth and does not fit the expected pattern of birth moulding, a palpable ridge along a skull suture, an unusually small or early-closing fontanelle, abnormal head growth, or other clinical findings that raise concern (Kapp-Simon et al., 2021). An unusual head shape does not itself mean that a baby has craniosynostosis, but craniosynostosis needs to be considered where the shape or examination findings are atypical. Early recognition is important because its management differs substantially from positional skull deformation (Kapp-Simon et al., 2021; Wilkie, Johnson and Wall, 2017). Everyday ways to support healthy head movement and shape For babies with positional plagiocephaly or brachycephaly, everyday positioning can help reduce the amount of time spent putting pressure on the same area of the skull. What is appropriate will depend on the baby's age, development, neck movement and the pattern and severity of the asymmetry. During awake periods, giving the baby opportunities to move their head freely can help vary the areas of the skull that are exposed to pressure. Supervised tummy time is one way of doing this, and short, frequent periods can be incorporated into ordinary daily activities such as being held, playing on the floor or spending time with a caregiver (Kluba et al., 2017; Zhang et al., 2024). When a baby consistently looks towards one side, everyday activities can sometimes be arranged so that there is an interesting reason to look towards the less-preferred side. For example, during awake and supervised floor time, a caregiver can position themselves, toys or other visual interest on the side the baby is less inclined to turn towards. Varying which arm the baby is carried in and changing the direction from which interaction takes place can also provide opportunities for the baby to look in different directions. For many babies, positional flattening becomes less noticeable as they develop stronger head control, spend more time upright and become increasingly mobile. The appropriate approach therefore changes with the baby's development rather than relying on one particular positioning strategy (Bialocerkowski, Vladusic and Wei Ng, 2008; Zhang et al., 2024). Infant body therapies and hands-on approaches Some families seek an infant body-therapy or hands-on approach when a baby has a positional preference, musculoskeletal asymmetry or concern about cranial shape. Different approaches have different proposed mechanisms, scopes of practice and evidence bases, so evidence relating to one intervention should not automatically be applied to another. The evidence also needs to be considered in relation to the outcome being studied. A study looking at a change in cranial measurements, for example, does not necessarily tell us whether an intervention improves breastfeeding, sucking, milk transfer or another aspect of feeding. Osteopathic treatment is one example that has been studied in infants with positional cranial deformation. A 2022 randomised controlled trial reported greater improvement in measured cranial asymmetry among infants who received six sessions of osteopathic manipulative treatment alongside repositioning than among infants who received repositioning with light-touch treatment (Bagagiolo et al., 2022). A more recent randomised controlled trial investigated osteopathic treatment intended to prevent positional cranial deformity in newborns considered to be at risk. It did not find a statistically significant reduction in plagiocephaly or brachycephaly, although the study ended early because recruitment was lower than planned and was therefore underpowered to determine whether a smaller effect might exist (Genelot et al., 2025). These studies illustrate why the evidence needs to be considered carefully rather than treating a change in skull shape as equivalent to an improvement in feeding function. A reduction in measured asymmetry does not, by itself, demonstrate improved sucking, milk transfer or breastfeeding outcomes. For families considering an infant body-therapy or hands-on approach, it is reasonable to look at what the practitioner is proposing, their relevant qualifications and scope of practice, and the evidence available for that particular intervention. This can sit alongside appropriate medical and feeding assessment rather than being presented as an alternative to either. Looking at the whole feeding picture A baby with an asymmetrical head may feed comfortably and effectively, while another baby with relatively subtle asymmetry may experience difficulties with attachment, endurance or milk transfer. The visible shape of the skull therefore cannot tell us whether feeding will be affected. A useful feeding assessment considers the relationship between the baby's head, neck, spine, trunk, jaw and mouth and, where possible, observes how these structures work together during an actual feed. Milk flow, feeding method, the baby's state, oral anatomy, sucking and swallowing, breathing, milk transfer and the comfort of the feeding parent or caregiver are also relevant. This wider view is important because asymmetry does not necessarily originate in the skull. A baby may have restricted neck movement, a positional preference or another musculoskeletal difference that influences both head shape and feeding position. In other circumstances, a visible skull asymmetry may be present without causing any functional difficulty. The useful question is therefore not simply what shape the baby's head has, but how the baby's head, neck, spine, jaw and mouth are working together during feeding and whether there is evidence that this relationship is affecting function. When feeding concerns need prompt attention Whatever a baby's head shape, feeding concerns need to be considered in their own right. A baby who is feeding poorly, is difficult to wake for feeds, has significantly fewer wet nappies than expected, shows signs of dehydration, is repeatedly vomiting, appears unwell or is not gaining weight as expected needs appropriate clinical assessment. These concerns should not automatically be attributed to head shape without considering the wider clinical picture. References Bagagiolo, D., Priolo, C.G., Favre, E.M., Pangallo, A., Didio, A., Sbarbaro, M., Borro, T., Daccò, S., Manzoni, P. and Farina, D. (2022) ‘A randomized controlled trial of osteopathic manipulative therapy to reduce cranial asymmetries in young infants with nonsynostotic plagiocephaly’, American Journal of Perinatology, 39(S01), pp. S52–S62. Available at: https://pubmed.ncbi.nlm.nih.gov/36451623/ Bialocerkowski, A.E., Vladusic, S.L. and Wei Ng, C. (2008) ‘Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review’, Developmental Medicine & Child Neurology, 50(8), pp. 577–586. Available at: https://pubmed.ncbi.nlm.nih.gov/18754894/ D'Heilly, C., Conroy, E.J., McCarty, E., Knapp, J., Cray, J.J. and Gosain, A.K. (2007) ‘Mandibular asymmetry in infants with deformational plagiocephaly’, Journal of Craniofacial Surgery, 18(6), pp. 1283–1288. Available at: https://pubmed.ncbi.nlm.nih.gov/17900639/ Di Ieva, A., Bruner, E., Rychlicki, F., Tschabitscher, M. and Turgut, M. (2017) ‘A comprehensive review of the anterior fontanelle: embryology, anatomy, and clinical considerations’, Child's Nervous System, 33, pp. 909–914. Available at: https://pubmed.ncbi.nlm.nih.gov/28396968/ Dias, M.S. and Samson, T. (2017) ‘Cranial deformation in infancy’, in Diagnosis of Infant Synostotic and Nonsynostotic Cranial Deformities: A Review for Pediatricians. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5176072/ Genelot, C., Macioce, V., Huguet, H., Harrewijn, I., Cambonie, G., Dessauge, D., Mura, T., Moulis, L. and Captier, G. (2025) ‘Early osteopathic manipulative treatment to prevent cranial positional deformities: a randomized controlled trial’, Archives de Pédiatrie, 32(3), pp. 203–209. Available at: https://pubmed.ncbi.nlm.nih.gov/39875214/ Genna, C.W. (2015) ‘Breastfeeding infants with congenital torticollis’, Journal of Human Lactation, 31(2), pp. 216–221. Available at: https://pubmed.ncbi.nlm.nih.gov/25616913/ Kapp-Simon, K.A., Collett, B.R., Cradock, M.M., McGrath, A.M. and Cunningham, M.L. (2021) ‘Diagnosis and management of suture-related concerns of the infant skull’, Pediatrics in Review, 42(8), pp. 401–412. Available at: https://pubmed.ncbi.nlm.nih.gov/34247705/ Kluba, S., Kraut, W., Calgeer, B., Reinert, S. and Krimmel, M. (2017) ‘Treatment of positional plagiocephaly – a systematic review of the evidence’, European Journal of Pediatrics, 176, pp. 127–135. Available at: https://pubmed.ncbi.nlm.nih.gov/?term=Kluba+Kraut+Calgeer+Treatment+of+positional+plagiocephaly+2017 Lipsett, B.J., Reddy, V. and Steanson, K. (2023) ‘Anatomy, head and neck: fontanelles’, StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK542197/ Moczygemba, C.K., Paramsothy, P., Sappenfield, W.M., Kahn, B.F., Lu, G.C. and McDonald, J.R. (2004) ‘The immediate effects of forceps and vacuum-assisted deliveries on neonatal health’, American Journal of Obstetrics and Gynecology, 191(6), pp. 1911–1916. Available at: https://pubmed.ncbi.nlm.nih.gov/14990415/ NHS (2025) ‘Breastfeeding: positioning and attachment’. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/positioning-and-attachment/ Paglia, L. (2026) ‘Breastfeeding and craniofacial development: current evidence and future directions’. Available at: https://pubmed.ncbi.nlm.nih.gov/41777226/ Shah, M., Hallacq, P. and Van Loveren, R. (2016) ‘Development and growth of the normal cranial vault: an embryologic review’, Journal of Korean Neurosurgical Society, 59(3), pp. 245–252. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4877539/ Souza, J.P., Ross, M.G. and Milner, R.D.G. (1976) ‘Changes in neonatal head dimensions following caesarean and vaginal delivery’, Archives of Disease in Childhood, 51(7), pp. 538–541. Available at: https://pubmed.ncbi.nlm.nih.gov/962373/ St John, D., Mulliken, J.B., Kaban, L.B. and Padwa, B.L. (2002) ‘Mandanular asymmetry in deformational posterior plagiocephaly’, Journal of Oral and Maxillofacial Surgery, 60(7), pp. 748–753. Available at: https://pubmed.ncbi.nlm.nih.gov/12149730/ Stellwagen, L., Hubbard, E., Chambers, C. and Jones, K.L. (2008) ‘Torticollis, facial asymmetry and plagiocephaly in normal newborns’, Pediatrics, 112(3), pp. 529–534. Available at: https://pubmed.ncbi.nlm.nih.gov/18381343/ The BASIS Team (2025) ‘Sleep, health and safety’. Baby Sleep Information Source (BASIS). Available at: https://www.basisonline.org.uk/sleep-health-safety/ The Lullaby Trust (2026) ‘Mattresses, bedding and flat head syndrome’. Available at: https://www.lullabytrust.org.uk/baby-safety/baby-product-information/mattresses-and-bedding/ Wall, V. and Glass, R.P. (2006) ‘Mandibular asymmetry and breastfeeding problems: experience from 11 cases’, Journal of Human Lactation, 22(3), pp. 328–334. Available at: https://pubmed.ncbi.nlm.nih.gov/16885493/ Wilkie, A.O.M., Johnson, D. and Wall, S.A. (2017) ‘Clinical genetics of craniosynostosis’, Current Opinion in Pediatrics, 29(6), pp. 622–629. Available at: https://pubmed.ncbi.nlm.nih.gov/?term=Wilkie+Johnson+Wall+Clinical+genetics+of+craniosynostosis Zhang, Y., et al. (2024) ‘Nonobstetric risk factors for deformational plagiocephaly: a systematic review and meta-analysis’. Available at: https://pubmed.ncbi.nlm.nih.gov/39292504/

Colostrum can be collected before a baby is born, and for some families this can be a useful option to have available after birth. For others, antenatal hand expression may not be necessary or appropriate. Collecting colostrum before birth is not a requirement for breastfeeding, and the amount collected during pregnancy does not tell you how much milk you will produce after your baby is born. What is antenatal hand expression? Antenatal hand expression is the process of expressing colostrum by hand during the final weeks of pregnancy and collecting it for use after your baby is born. Colostrum is the first milk produced by the breasts. It is concentrated and contains nutrients, antibodies and other components that support your newborn during the first days of life (CUH, 2023). Colostrum is produced from relatively early in pregnancy, but actively expressing it is generally discussed from around 36–37 weeks, depending on your individual circumstances and local maternity guidance (CUH, 2023). The term "colostrum harvesting" is sometimes used to describe antenatal collection. When might antenatal hand expression be considered? Antenatal expression may be discussed where there is a reason to anticipate that a baby could benefit from having expressed colostrum available after birth. This can include: diabetes in pregnancy, where a baby may be more likely to experience low blood glucose after birth a baby who is expected to need additional support with feeding a baby who may need care on a neonatal unit some situations where a baby's growth or health has been a concern during pregnancy some multiple pregnancies other circumstances identified by the maternity team. The evidence for antenatal expression has mainly focused on pregnancies where there is a particular reason to anticipate a need for expressed colostrum, especially diabetes in pregnancy. In the DAME trial, women with diabetes in pregnancy who were at low risk of complications were advised to hand express twice daily from 36 weeks. The study found no evidence that this increased neonatal intensive care admission compared with standard care (Forster et al., 2017). This does not mean that antenatal expression is necessary for everyone. Your maternity team can help you decide whether it is appropriate in your circumstances. When antenatal hand expression is not advised > Antenatal hand expression can stimulate the release of oxytocin, which can cause uterine contractions and may potentially trigger labour. If you have any circumstances that could increase concern about premature birth or other pregnancy complications, do not start antenatal hand expression without first discussing it with your maternity team. This may include: a history or increased risk of premature labour a shortened cervix a cervical stitch vaginal bleeding during pregnancy a low-lying placenta or placenta praevia ruptured membranes or fluid loss some multiple pregnancies concerns about your baby's wellbeing any other pregnancy complication where your maternity team has advised avoiding nipple stimulation. The DAME trial found no evidence of harm from antenatal expression from 36 weeks in women with diabetes who were considered to be at low risk of complications (Forster et al., 2017). This does not mean that antenatal expression is appropriate in every pregnancy. If you are expressing and experience regular or painful contractions, vaginal bleeding, fluid loss, reduced fetal movements or anything else that concerns you, stop expressing and contact your maternity team or maternity triage for advice. When is antenatal expression usually started? Many maternity services recommend starting around 36–37 weeks of pregnancy. The exact timing varies between services and depends on individual circumstances. For example, the DAME trial began antenatal expression at 36 weeks in women with diabetes who were considered to be at low risk of complications (Forster et al., 2017). Your own maternity team's advice should take priority over a general timeframe. How do you hand express colostrum? Antenatal colostrum is collected by hand rather than with a breast pump. Before you start: Wash your hands thoroughly. Find somewhere comfortable and warm where you can relax. Gentle breast massage or a warm shower or flannel may help you feel more comfortable and encourage milk release. Have your sterile collection syringe or other equipment ready. To hand express: 1. Place your thumb and finger in a C-shape around the breast, a little way back from the nipple. 2. Gently press your fingers back towards your chest, rather than squeezing the nipple. 3. Keeping your fingers in position, gently compress and release them rhythmically. Avoid sliding your fingers over the skin. 4. When the flow slows, move your fingers around the breast to express from a different area. You can then repeat the process on the other breast. It can take a little while before colostrum appears. You may see tiny beads or drops initially, although the amount can vary considerably between women and between expressing sessions. Hand expression should not be painful. If it is uncomfortable, stop and check your technique with your midwife or infant feeding team. For more information about hand expression, see How to Express Breastmilk. How much colostrum should you expect? There is no set amount that you should be able to collect. Some women may initially see only a glisten of colostrum or collect less than 1 ml, while others may collect considerably more. Both can be normal. The amount collected can also change from one expressing session to another. Not seeing much colostrum does not mean that you will not produce milk after your baby is born. Colostrum is concentrated and newborn babies need relatively small amounts in the early days. This is why 1 ml syringes are commonly used for antenatal collection (CUH, 2023). Colostrum catchers and syringes Your maternity service may provide syringes or a colostrum catcher for collecting antenatally expressed colostrum. It is worth checking with your maternity team which equipment they recommend and whether there are any specific requirements for bringing your collected colostrum into hospital. Some maternity services use syringes with a securely attached cap for collection and storage. You may also be asked to place your labelled syringes into a labelled freezer bag before freezing. The exact arrangements vary between maternity services, so check what your hospital asks you to use before you start collecting. Your maternity service may provide its own syringes, labels and storage bags. If so, use the equipment supplied and follow their instructions rather than substituting different products. Because local systems differ, also check whether your maternity service accepts antenatally collected colostrum brought into hospital and, if so, how they want it prepared for admission. Labelling and storing antenatal colostrum Your maternity service can tell you exactly how they want your colostrum labelled and stored. Common requirements include labelling the individual syringe with details such as your name, date of birth or hospital number, together with the date and time of expression. Some services also ask for the volume collected, particularly where a label covers the syringe markings. Some NHS services ask for the labelled syringes to be placed into a clean, sealed or resealable freezer bag, with the bag itself labelled with identifying details. Others have different systems so its worth finding out in advance and follow the instructions provided by your chosen maternity service. Taking frozen colostrum into hospital Check with your maternity service before your baby is born about whether they want you to bring your frozen colostrum in when you are admitted. This is particularly important because hospitals do not all have the same facilities for storing antenatally expressed colostrum. Some maternity services ask families to bring only a small number of frozen syringes initially, with further syringes brought in if they are needed. This can reduce the chance of colostrum thawing before it is required. Frozen colostrum should normally be transported in a cool bag with frozen ice packs and handed to the maternity staff on arrival so that they can advise you about local storage arrangements. What happens when frozen colostrum is thawed? Storage and thawing instructions vary slightly between maternity services. Once frozen colostrum has been completely thawed, it should not be refrozen. The time it can be kept after thawing also depends on the local guidance. Some NHS services specify that it should be used within 24 hours, while others have much shorter time limits. This is one reason why maternity services may recommend bringing only a small amount of frozen colostrum into hospital. What happens to the colostrum after your baby is born? How and when your antenatally expressed colostrum is used will depend on your baby's individual circumstances. If your baby is feeding effectively and does not need additional milk, you may not need to use the colostrum you have collected antenatally. If additional milk is indicated, your own expressed colostrum may be one of the options discussed with you. Your maternity team can advise you about how it can be given alongside responsive feeding and ongoing breast stimulation. Having colostrum stored does not replace skin-to-skin contact, responsive feeding or support with positioning and attachment. It is simply something that may be useful to have available if it is needed. You can read more about breastfeeding latch and positioning and increasing breast milk production in our other articles. References Association of Breastfeeding Mothers (n.d.) Hand expressing. Available at: https://abm.me.uk/breastfeeding-information/hand-expressing/ Cambridge University Hospitals NHS Foundation Trust (2023) Antenatal hand expression of breast milk guidance. Available at: https://www.cuh.nhs.uk/patient-information/antenatal-hand-expression-of-breast-milk-guidance/ East Lancashire Hospitals NHS Trust (n.d.) Antenatal hand expressing colostrum. Available at: https://elht.nhs.uk/services/maternity-and-newborn-services/infant-feeding/antenatal-hand-expressing-colostrum Forster, D.A. et al. (2017) ‘Advising women with diabetes in pregnancy to express breast milk in late pregnancy (DAME): a multicentre, unblinded, randomised controlled trial’, The Lancet, 389(10085), pp. 2204–2213. Available at: https://pubmed.ncbi.nlm.nih.gov/28589894/ Foustanellas, A. et al. (2021) ‘Antenatal breast milk expression: a scoping review’, Women and Birth. Available at: https://pubmed.ncbi.nlm.nih.gov/33712049/ Hull University Teaching Hospitals NHS Trust (2024) Antenatal Colostrum Collection. Available at: https://www.hey.nhs.uk/patient-leaflet/33253/ Leeds Teaching Hospitals NHS Trust (n.d.) Antenatal hand expressing. Available at: https://www.leedsth.nhs.uk/patients/resources/antenatal-hand-expressing/ NHS England (2026) Neonatal choking hazard from colostrum syringe caps. Available at: https://www.england.nhs.uk/long-read/neonatal-choking-hazard-from-colostrum-syringe-caps/ Right Decisions (2024) Antenatal colostrum harvesting. Available at: https://rightdecisions.scot.nhs.uk/maternity-gynaecology-guidelines/maternity/antenatal-general/antenatal-colostrum-harvesting-1154/ Sobik, M. et al. (2023) ‘Education and experiences of antenatal breast milk expression: a systematic review’, Breastfeeding Medicine, 18(2), pp. 107–115. Available at: https://pubmed.ncbi.nlm.nih.gov/36724491/

Breastfeeding can last for a day, several months, a couple of years or longer. Whenever your breastfeeding journey comes to an end, it is a change in feeding rather than a measure of how well you have done. There are many different reasons why someone may decide to stop breastfeeding. Health, medication, returning to work, changes within the family, feeding difficulties or simply feeling that the time is right can all be part of that decision. Research exploring why mothers stop breastfeeding has found that the reasons can be complex and can change throughout the first year (Li et al., 2008). The decision to stop may be completely baby-led, completely mother-led, or somewhere in between. It may also be a gradual change rather than a single decision to stop altogether. The Academy of Breastfeeding Medicine recognises that weaning can happen in different ways and that families may combine breastfeeding with expressed milk, formula or other forms of feeding during the transition (ABM, 2026). The reasons for stopping are not the focus here. Instead, this article looks at what stopping breastfeeding can involve, what your baby may need as feeds change, and how you can look after yourself and your breasts during the transition. However you choose to stop, your own wellbeing matters too. Weaning is a hormonal journey as well as a feeding journey, and some mothers find that the end of breastfeeding brings unexpected emotions, even when the decision feels right. Looking after yourself with regular food, a balanced diet, rest where possible, enough fluid to respond to your thirst, and practical or emotional support can make a difference. Stopping breastfeeding also opens another journey rather than simply bringing one to an end. There is no set age to stop breastfeeding There is no particular age when breastfeeding has to stop. The NHS describes when breastfeeding ends as a decision for you and your baby, while the World Health Organization recommends exclusive breastfeeding for around the first six months, followed by complementary foods alongside continued breastfeeding to two years and beyond, for as long as mutually desired (NHS, 2026a; WHO, 2026). Natural weaning is usually a gradual process. A baby may become increasingly interested in food, other ways of drinking, exploring their surroundings and the wider world around them while still enjoying breastfeeds. It is uncommon for a baby to completely self-wean during early infancy. A change in feeding behaviour does not necessarily mean that a baby is ready to stop breastfeeding altogether, particularly during periods of illness, developmental change or changes in routine. There is therefore no need to stop simply because your baby has reached a particular age. Equally, there is no requirement to continue beyond the point that feels right for you and your baby. What does weaning actually mean? The word weaning can mean different things to different families. Sometimes weaning refers to introducing solid foods. Sometimes it means gradually reducing breastfeeding. It may mean moving from direct breastfeeding to expressed breast milk, introducing formula, combining breastfeeding with another form of feeding, or gradually stopping breast milk altogether. These changes do not have to happen all at once. You may continue breastfeeding some of the time while replacing other feeds. You may keep a morning or bedtime breastfeed for much longer than daytime feeds. You may reduce feeds during the day while continuing to breastfeed at night. There is no requirement for weaning to be an all-or-nothing process. It is also worth separating the introduction of complementary foods from stopping breast milk. From around six months, babies can begin to explore solid foods, but breast milk or first infant formula remains an important source of nutrition during the first year (NHS, 2026b). What does my baby need instead? What replaces a breastfeed depends largely on your baby's age and what you want feeding to look like after breastfeeding reduces. Under 12 months old For babies under 12 months, breast milk or first infant formula remains their main drink. If breastfeeding is stopping and expressed breast milk is not being used, first infant formula is the appropriate replacement milk (ABM, 2026; NHS, 2026c). From around six months, babies can begin drinking from a cup as they develop the skills to do so. An open cup or free-flow cup without a valve can help babies learn to sip, and offering a cup with meals can become part of everyday feeding (NHS, 2026c). If you are moving from breastfeeding to bottles, paced bottle feeding can help keep the feeding experience responsive to your baby's cues. If you are choosing another way of offering milk, there are also alternatives to bottles. You can read more in my blogs [Alternative Feeding Methods for Babies] and [How to Pace Bottle Feeds]. Cows' milk can be used in cooking or mixed into foods from around six months, but it should not be given as a main drink until your baby is 12 months old. This is an important distinction: when NHS guidance refers to cows' milk from around six months, it means as part of food rather than as the milk drink replacing breast milk or first infant formula (NHS, 2026b; NHS, 2026c). From 12 months old From 12 months, pasteurised whole cows' milk can be offered as a main drink. Breast milk can also continue if you and your child wish to do so. Toddler or growing-up milks are not needed routinely after 12 months. The NHS recommends full-fat dairy products for children under two because young children need the energy and nutrients they provide (NHS, 2026d). How can breastfeeding be stopped? There is no single method that suits every feeding dyad. For many families, gradually reducing breastfeeds is the most comfortable approach, but there are several ways to make a transition. Gradual reduction Gradually reducing milk removal gives your breasts time to adjust as your milk production decreases. You might choose to: replace one breastfeed each day with another form of feeding shorten particular breastfeeds gradually increase the time between breastfeeds reduce particular feeds while continuing others remove daytime feeds while keeping a morning or bedtime feed reduce the frequency or duration of feeds over a period of weeks or months. There is no fixed timetable. Some families make changes over several days, while others take several weeks or longer. The important thing is that you do not have to stop every feed at the same time. Gradual reduction can also help reduce the likelihood of uncomfortable breast fullness and may reduce the risk of inflammation or mastitis associated with sudden changes in milk removal (ABM, 2026; NHS, 2026e). If you are only reducing some breastfeeds, you may not need to stop milk production altogether. Partial weaning can be a long-term feeding arrangement in its own right. Expressing may be part of the transition Expressing can be another way of managing the transition, particularly if you want to continue giving your baby breast milk while reducing or stopping direct breastfeeding. It is important to remember that expressed milk volume is not a direct measurement of how much milk your body produces. Milk production and milk removal are related, but they are not the same thing. The amount collected by a breast pump is influenced by the pump and its settings, flange fit, timing, breast fullness, milk ejection and the individual's response to expressing. Research also shows that milk output can vary considerably between breasts and between expressing sessions (Wambach et al., 2007; Geddes et al., 2023). Milk yield, viscosity and composition can also change during and between expressing sessions. A particular pumping session therefore cannot tell you exactly how much milk you produce or what your baby would have removed at the breast. For example, the fat content of human milk changes as the breast is progressively emptied, and the average 24-hour fat content can differ from the fat concentration measured in an individual expressing session (Daly et al., 1993; Kent et al., 2013). You can read more about expressing in my blogs How to Express Breastmilk and Breast Pump Flange Fitting: Size, Shape, Comfort and Milk Removal. If your breasts become uncomfortably full while feeds are being reduced, you do not necessarily need to fully empty them. Expressing a small amount for comfort can take the edge off the pressure while allowing milk removal to continue reducing. The aim is comfort rather than completely draining the breast, because removing more milk provides a signal for the body to continue producing it. Ways of reducing milk production As milk removal reduces, milk production normally reduces too. There are also some approaches that can be used alongside gradual reduction to make the physical transition more comfortable or to support lactation suppression. Cold therapy Cold therapy is widely used as part of lactation suppression and is included in NICE guidance as a self-help measure when breastfeeding has stopped or needs to be stopped (NICE, 2021). Cold packs or cold compresses can reduce discomfort, swelling and breast congestion during the transition. They can be particularly useful when the breasts feel full or tender. Cold therapy does not need to be extreme. A cold pack wrapped in a cloth can be applied for a short period, allowing the skin to warm again afterwards. Some people also find chilled cabbage leaves comfortable. Cold therapy is about supporting the physiological transition and making breast fullness more manageable; it does not mean that you need to tolerate significant pain or leave your breasts painfully overfull. Herbal remedies A number of herbs have traditionally been used to reduce milk production, including sage, peppermint, parsley and jasmine. Chasteberry has also been described in relation to reducing milk supply. The evidence is very different between these remedies, and traditional use should not be confused with good evidence that a particular herb will reliably reduce milk production. Information about these herbs is not a recommendation to use them, and this article does not provide instructions for preparation, dosage or frequency. An herb used as a food ingredient is not necessarily equivalent to a concentrated tea, tincture, capsule, extract or other supplement. The strength and ingredients of herbal products can vary, and the effects of some preparations on health, milk production and breastfed babies are not well understood. Herbal medicines can have pharmacological effects and can interact with medicines or affect how medicines work. This is particularly important if you take medication for a health condition or are using hormonal medicines, including contraception. Your underlying health conditions and current medicines may also themselves affect milk production. For example, medicines used for thyroid conditions and diabetes can be relevant when considering changes in milk supply, while some hormonal contraceptives can also affect lactation. Do not stop, reduce or change a prescribed medicine in an attempt to alter your milk supply. If you are considering using an herb or herbal preparation while reducing or stopping breastfeeding, speak with a pharmacist, GP, appropriately qualified healthcare professional or other professional who can check the specific preparation against your medical history, current medicines and other supplements. This is particularly important because safety information may be limited and some products have not been adequately studied during breastfeeding. Sage is traditionally used for weaning and oversupply, but LactMed reports that no scientific studies evaluating its effect on milk supply could be located. Sage also contains compounds including thujone and camphor, which can be neurotoxic in high doses, and there are limited safety data for breastfeeding mothers and infants (LactMed, 2025a). Peppermint is also traditionally used to suppress milk production. Laboratory and animal research suggests that menthol can affect milk production, but no clinical trials demonstrating lactation suppression in humans have been identified. Large amounts of peppermint can also cause gastrointestinal symptoms, and some peppermint constituents pass into breast milk (LactMed, 2025b). Parsley has been included in traditional preparations intended to reduce milk flow, but LactMed reports that there are no scientifically valid clinical trials supporting this use (LactMed, 2024a). Jasmine has a history of traditional use for lactation suppression, and one study found that applying jasmine leaves to the breasts reduced postpartum lactation. However, the study was considered low quality and there are insufficient data about safety and effectiveness (LactMed, 2021). Chasteberry has also been used traditionally to reduce milk supply, but the evidence is uncertain. Importantly, LactMed advises avoiding chasteberry during lactation because of concerns about its safety and its potential effects on lactation (LactMed, 2024b). Medicines and other factors that can affect milk production Some medicines can affect milk production. One example is pseudoephedrine, a decongestant sometimes known by the brand name Sudafed. Research has found that a single dose can temporarily reduce milk production and that repeated use can interfere with lactation (LactMed, 2026). This does not make pseudoephedrine a routine weaning treatment. It is a medicine with its own contraindications, interactions and potential adverse effects, so it should not be used specifically to stop breastfeeding without appropriate individual medical advice. It is also worth remembering that medicines and health conditions can affect milk production in different ways. If your milk production has changed unexpectedly, or you are taking medication for a long-term health condition, discuss this with your healthcare professional rather than assuming that the medication or condition should simply be changed. If breastfeeding needs to stop more quickly Sometimes gradual reduction is not possible or is not what someone needs. There may be a medical reason, an urgent change in circumstances, medication that makes breastfeeding temporarily or permanently unsuitable, pregnancy or infant loss, or a situation in which continuing to breastfeed is affecting a mother's physical or emotional wellbeing. If mental health or a sense of safety is part of the reason that breastfeeding needs to stop quickly, that matters too. You do not need to justify your decision before receiving support. Stopping abruptly Stopping suddenly means that milk removal decreases much more quickly, which can leave the breasts feeling very full, painful or swollen. If stopping abruptly is necessary, reducing breast stimulation and expressing only enough milk to relieve significant discomfort can help. Cold packs, a comfortable supportive bra and appropriate pain relief may also help with symptoms (NICE, 2021). If you develop a worsening painful area, increasing redness or swelling, fever, flu-like symptoms or feel significantly unwell, seek medical advice rather than assuming that you simply need to push through the discomfort (NHS, 2026e). Medication to suppress lactation Cabergoline is a prescription medicine that suppresses prolactin and can be used to inhibit or suppress physiological lactation in specific circumstances. If you think medication may be appropriate because breastfeeding needs to stop quickly, this is something to discuss with your GP, midwife, obstetric team or another appropriate healthcare professional. It may be considered after childbirth when breastfeeding is not going to be started, when breastfeeding is contraindicated for medical reasons, or following stillbirth or abortion. It may also be used in other specific medical circumstances following clinical assessment (eMC, 2025). Cabergoline is therefore not a self-help method or a routine shortcut for planned weaning. Whether it is appropriate depends on the individual circumstances, medical history and reason for lactation suppression. What about breast binding? Tightly binding or compressing the breasts is not recommended as a way of stopping breastfeeding. Breast binding is an old method of attempting to suppress milk production, but it is no longer recommended. Research has not demonstrated a useful benefit from binding, and it can increase breast discomfort, tenderness and leakage. It may also place unnecessary pressure on breast tissue. A comfortable, supportive bra can provide support while the breasts are changing, but tight compression is not needed to reduce milk production and can cause unnecessary pain and discomfort. There are now more comfortable and evidence-informed approaches to managing breast fullness during weaning, including gradual reduction of milk removal, expressing small amounts for comfort when necessary and cold therapy. Looking after yourself while weaning Stopping breastfeeding is a physical and hormonal change as well as an emotional one. As milk production changes, hormone levels change too. Some mothers notice very little emotional change, while others experience sadness, irritability, tearfulness or a sense of loss around the end of breastfeeding. This can happen even when stopping feels completely right. Regular meals, enough fluid according to thirst, rest where possible and support from people you trust can all be useful during the transition. It can also help to give yourself permission to notice the emotions without assuming that they mean you have made the wrong decision. If you experience persistent low mood, significant anxiety, intrusive thoughts or feel that you are struggling to cope, seek appropriate support. When your breastfeeding journey comes to an end Whether your breastfeeding journey lasted a day, several months, a year, several years or longer, it was part of your relationship with your baby. There does not need to be a particular way for the journey to end. It may happen gradually, one feed at a time. It may involve expressed milk, formula, cups, bottles, solid foods or a combination of different ways of feeding. It may be entirely your decision, entirely your baby's timing, or something you navigate together. Stopping breastfeeding does not erase everything that came before it. It is simply a change in feeding — and the beginning of another stage in your journey together. References Academy of Breastfeeding Medicine (2026) Questions mums ask about stopping breastfeeding. Patient information leaflet. 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(4), pp. 543–551. https://pubmed.ncbi.nlm.nih.gov/8311942/ eMC (2025) Cabergoline 0.5mg Tablets: Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/101200/smpc Geddes, D.T., Gridneva, Z., Perrella, S.L., Mitoulas, L.R., Kent, J.C. and Hartmann, P.E. (2023) ‘Infant factors that impact the ecology of human milk secretion and composition’, Frontiers in Nutrition, 10. https://pmc.ncbi.nlm.nih.gov/articles/PMC10356564/ LactMed (2021) Jasmine. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501843/ LactMed (2024a) Parsley. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501880/ LactMed (2024b) Chasteberry. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501807/ LactMed (2025a) Sage. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501816/ LactMed (2025b) Peppermint. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501851/ LactMed (2026) Pseudoephedrine. Drugs and Lactation Database. National Library of Medicine. Li, R., Fein, S.B., Chen, J. and Grummer-Strawn, L.M. (2008) ‘Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year’, Pediatrics, 122(Supplement 2), pp. S69–S76. https://doi.org/10.1542/peds.2008-1315i National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. https://www.nice.org.uk/guidance/ng194 NHS (2026a) How to stop breastfeeding. NHS. NHS (2026b) Your baby's first solid foods. NHS. NHS (2026c) Drinks and cups for babies and young children. NHS. NHS (2026d) What to feed young children. NHS. NHS (2026e) Mastitis. NHS. Wambach, K.A., Spencer, B., March, K., Lairson, P. and Arnold, L. (2007) ‘Comparison of milk output between breasts in pump-dependent mothers’, Journal of Human Lactation, 23(4), pp. 399–405. https://doi.org/10.1177/0890334407307575 World Health Organization (WHO) (2026) Breastfeeding. WHO.

“Has my baby’s tongue-tie reformed?” is an understandably worrying question, particularly when feeding remains difficult or the area under the tongue looks different during healing. Tongue-tie reformation is a term often used to describe concern that restriction has returned after a frenulotomy. It is not, however, a precise diagnosis. A careful response starts with the infant’s feeding, comfort and tongue function, rather than appearance alone. For families, this uncertainty can feel especially hard after making a considered decision about a procedure. For professionals, it is a reminder that anatomy provides information, while function provides context. Healing, feeding and infant development are dynamic, and a thoughtful review is more useful than assuming that every ongoing difficulty represents recurrent restriction. What does tongue-tie reformation mean? In everyday conversation, reformation may refer to several different things: normal healing tissue being visible, a frenulum that appears prominent again, scar tissue, or a concern that tongue movement is limited after a previous release. These are not interchangeable findings, and none can confirm a clinically significant problem without considering function and feeding. The published literature does not offer a consistent definition of reformation or reattachment after infant frenulotomy. Studies use differing terminology, outcome measures and follow-up periods. This makes it difficult to quote a reliable rate or to know whether reports from one setting apply to another. It also means that a visual finding, taken in isolation, should be interpreted cautiously. A frenulum is a normal anatomical structure. Following a frenulotomy, the area heals and its colour, texture and appearance may change over time. A pale or yellowish healing surface can be part of normal wound healing, but photographs or remote descriptions cannot reliably distinguish normal healing from a problem. Families should be offered clear aftercare information and an appropriate route to seek review when something does not feel right. Why feeding may still be difficult Frenulotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term feeding outcomes is less certain. A Cochrane review found that the small trials available suggested short-term improvement in nipple pain, while demonstrating inconsistent effects on infant breastfeeding measures (O’Shea et al., 2017). Systematic reviews have similarly identified limitations in study size, follow-up and outcome reporting (Francis et al., 2015). This matters when considering tongue-tie reformation. Continuing pain, clicking, lengthy feeds, milk transfer concerns or bottle-feeding difficulties may warrant support, but they do not automatically establish that a restriction has returned. Feeding can be influenced by positioning and attachment, milk supply, breast and nipple anatomy, infant prematurity, jaundice, neurological or muscular differences, reflux-like symptoms, flow preferences, bottle-feeding dynamics and the cumulative effect of a stressful feeding journey. Sometimes the original restriction may not have been the main contributor to the difficulty. At other times, feeding has become associated with tension or distress, and the infant and parent need skilled, unhurried support as they regain confidence. These possibilities are not a reason to dismiss a family’s concerns. They are a reason to assess the whole picture. Function needs to be observed, not presumed A meaningful review brings together the feeding history, parental experience, infant growth and wellbeing, observation of a feed where appropriate, and assessment of oral function within the clinician’s scope of practice. For breastfed babies, this may include comfort, attachment, audible swallowing and signs of milk transfer. For bottle-fed babies, it may include seal, coordination, endurance, coughing or spluttering, and whether feeding is comfortable and sustainable for the family. No single sign proves that a tongue-tie is causing a problem. Equally, an infant can have a visible frenulum and feed effectively. The Academy of Breastfeeding Medicine advises that tongue-tie is a functional diagnosis and that the presence of a sublingual frenulum alone is not an indication for surgery (Academy of Breastfeeding Medicine, 2021). What does the evidence say about aftercare? Families may encounter confident claims that a particular aftercare routine can prevent reformation. Current evidence does not support certainty here. There is insufficient high-quality evidence that manual manipulation of a healing frenulotomy site prevents reattachment or improves feeding outcomes. The Academy of Breastfeeding Medicine states that evidence is lacking to support manual manipulation or stretching at the surgical site after a frenulotomy (Academy of Breastfeeding Medicine, 2021). The American Academy of Pediatrics similarly advises against recommending post-frenotomy stretching exercises in which parents reopen the wound, noting the absence of evidence for benefit and the potential for harm or distress (Thomas et al., 2024). This does not mean families should be left without follow-up. It means follow-up should focus on healing, feeding, parental concerns and individual clinical need rather than a universal wound-focused routine. Gentle oral activities may sometimes be discussed by appropriately trained professionals as part of wider feeding support, but they are not a substitute for assessment and should not be presented as a guaranteed way to prevent reformation. The distinction matters: supporting feeding function is different from asking a parent to manage a healing wound. When should families seek a review? Contact the treating service, GP, midwife, health visitor or an appropriately qualified infant feeding professional if feeding pain is persisting or worsening, feeds are increasingly stressful, there are concerns about intake or growth, or the healing area causes concern. Urgent medical advice is needed if an infant is unwell, unusually sleepy, has a fever, refuses feeds, or there are signs of bleeding or infection. A follow-up appointment is also valuable when the question is simply, “Is this healing normally?” Reassurance has greatest value when it is based on seeing the infant and hearing the family’s experience, not on generalised advice. Parents do not need to prove that something is wrong before asking for support. For healthcare professionals, careful language can reduce anxiety. Rather than confirming “reformation” from appearance, describe the finding, ask what has changed in feeding, and consider plausible differential explanations. If concerns persist, collaborative review may involve the clinician who performed the frenulotomy, an infant feeding specialist and the infant’s wider healthcare team. Repeat procedures require careful reasoning A repeat frenulotomy should not be assumed to be the next step because feeding remains challenging or tissue is visible. The decision requires an individual assessment of potential benefit, uncertainty and burden, alongside conservative feeding support where appropriate. The evidence base does not support a one-size-fits-all pathway, and families deserve transparent discussion of what is known and what remains uncertain. Clinical consensus guidance emphasises the need for informed consent, appropriate assessment and attention to alternative causes of feeding difficulty (Messner et al., 2020). A family may decide that further assessment, targeted feeding support, watchful waiting or another clinical opinion best fits their circumstances. Each can be a valid, supported choice. A calmer way forward The language of tongue-tie reformation can make a complex healing and feeding experience sound simple: the tie is either back or it is not. In reality, the most useful question is often, “How is this baby feeding, growing and feeling now, and what support does this family need?” A skilled, compassionate review can make space for both the clinical findings and the lived experience behind 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. Francis, D.O., Krishnaswami, S. and McPheeters, M. (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.R., Simons, J.P., Wang, M.B., Walsh, S.A. and Wax, M.K. (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., et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 153(2), e2023064054.

Tongue-Tie Exercises After a Frenulotomy If your baby has had a tongue-tie divided, you may have been given advice about exercises afterwards. The phrase “tongue-tie exercises” can mean quite different things, though, and this is where things can become confusing. Some exercises are intended to help your baby learn to use their tongue more effectively after the restriction has been released. Others involve deliberately lifting, stretching, rubbing or manipulating the healing wound underneath the tongue. These are not the same thing. This distinction is particularly important because there is still no universally agreed approach to aftercare following infant frenulotomy. Different practitioners and organisations give different advice, and research into what is most helpful is continuing to develop. Why might a baby be offered tongue exercises? Dividing a tongue-tie releases a physical restriction, but it does not instantly give a baby perfect tongue strength, coordination or feeding skills. The tongue is a muscular structure that has been moving in a particular way since before birth. If its movement has been restricted, a baby may have developed compensatory ways of feeding or may simply have had less opportunity to practise certain movements. Think of it a little like giving someone more freedom of movement after they have been moving within a limited range. The freedom is important, but strength, coordination and confidence still develop through practice. The tongue has a number of movements and functions that are important for feeding. These include: lateralisation – moving from side to side cupping – forming a shape around the breast or teat spreading – widening and flattening across the palate extension – moving forwards protrusion – bringing the tongue beyond the lips snapback – returning the tongue into the mouth after extension peristalsis – the wave-like movement that helps move milk backwards vacuum or draw – helping to create and maintain the pressure needed for milk transfer These movements do not happen independently. Feeding is a coordinated activity, and a baby may be using several of them together during a single feed. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), for example, assesses a range of tongue movements and functions, although the terminology and number of functions used in different assessment systems can vary. After a frenulotomy, feeding itself provides an important opportunity for the baby to practise using the tongue in its newly available range. Additional tongue-function activities may sometimes be used to concentrate on an area where movement, strength or coordination appears less developed. The aim is therefore not simply to “exercise the tongue because it has been released”. The aim is to support function where it is actually needed. Tongue-function exercises are not wound stretches This is one of the most important distinctions to understand. Tongue-function exercises are intended to encourage movement or function of the tongue. They are not necessarily intended to interfere with the healing wound. Wound stretching or disruptive wound management is different. This involves deliberately manipulating the healing area underneath the tongue, for example by lifting the tongue to stretch the wound or rubbing or sweeping across the wound. The Association of Tongue-tie Practitioners (ATP) describes four levels of aftercare: 1. Level 1 – feeding as usual, without specific tongue exercises or deliberate wound manipulation. 2. Level 2 – feeding as usual alongside tongue exercises intended to encourage tongue movement and function. These are not intended to deliberately manipulate the healing wound. 3. Level 3 – lifting the tongue to stretch the healing wound. 4. Level 4 – disruptive wound management (DWM), involving active manipulation of the wound, such as sweeping, rubbing or circular massage, sometimes with the intention of stretching or opening the healing area. The important difference is that Levels 1 and 2 are focused on feeding and tongue function, whereas Levels 3 and 4 deliberately manipulate the healing wound. The ATP supports aftercare up to Level 2 and does not recommend routine Level 3 or Level 4 wound management. It also highlights that there is not yet published evidence demonstrating which level of aftercare produces optimal healing or prevents the need for a second frenulotomy. What is disruptive wound management? Disruptive wound management is sometimes recommended with the intention of preventing the wound from healing in a way that might restrict tongue movement. The reasoning is understandable. If the wound edges heal together, new tissue will form between them. It can therefore seem logical that repeatedly opening or stretching the wound might prevent a restrictive reattachment. However, the question is not simply whether wound manipulation can change the way a wound heals. The important question is whether deliberately disturbing the wound provides enough additional benefit to justify doing it routinely to every baby. There is emerging research in this area, including a 2025 US study which reported recurrent restriction in 5.6% of babies whose caregivers adhered to a postoperative stretching regimen, compared with 16% in the group who did not adhere to stretching (Miller et al., 2025). That finding is relevant and should not simply be dismissed. However, it does not establish that every baby needs wound stretching, nor can the figures be directly compared with the ATP's UK estimate of around 2–4% reformation or renewed restriction because these figures come from different populations, settings and methods. In fact, 5.6% is 1.6 percentage points above the upper end of the ATP's 2–4% estimate. That does not mean that stretching causes a higher rate, because the figures are not directly comparable. It does, however, illustrate why the question remains more complicated than simply assuming that more wound manipulation must always be better. The ATP also identifies a number of potential concerns with Levels 3 and 4, including pain and discomfort, difficulty for caregivers in carrying out the technique accurately, oral aversion or feeding strike, infection and the possibility of disturbing the healing process. For a procedure where the estimated rate of reformation or renewed restriction is already relatively low, any routine intervention that may be painful or distressing needs a clear and meaningful benefit to justify it. That does not mean that emerging research should be ignored. It means that families deserve to know that there is still uncertainty about the best approach, rather than being told that wound stretching is an established requirement after every frenulotomy. Expected wound healing It is also worth understanding what happens as the wound heals. After a frenulotomy, the edges of the wound need to heal. The body naturally repairs the area, with new tissue forming and then undergoing further remodelling as healing progresses. Some form of new tissue between the wound edges is therefore expected. This does not mean that the tongue-tie has returned. The inside of the mouth also heals differently from skin. Oral mucosa generally heals relatively quickly and tends to produce much less fibrotic scar tissue than skin, although healing still involves inflammation, new tissue formation and remodelling (Wong et al., 2009; Griffin et al., 2022). A healing wound may therefore look as though tissue is forming underneath the tongue. It may initially appear more prominent or feel firmer, and its appearance can change considerably as healing continues. Tissue can soften and become more pliable as remodelling takes place. Looking at the area alone cannot tell you whether the tongue has become functionally restricted again. What matters is function. If the tongue continues to move well and your baby's feeding is comfortable and effective, the presence or appearance of healing tissue does not automatically mean that the frenulum has reformed in a way that requires further treatment. This is one reason why deliberately disrupting the wound to try to prevent any tissue from forming is difficult to justify. The body has to heal the wound somehow. The aim is not to prevent tissue formation altogether. The aim is to allow the wound to heal while maintaining good tongue function. A visible area of healing tissue, or a change in appearance underneath the tongue, can therefore be completely compatible with a successful frenulotomy. A healed wound does not mean feeding function is complete There is another important distinction here: the wound healing and your baby's feeding development are two different things. A wound can be fully healed while your baby is still learning how to use their tongue effectively. Healing tells us that the tissue has repaired. It does not tell us that the tongue has reached its optimum strength, coordination, range of movement or feeding efficiency. If your baby has spent weeks or months adapting to restricted tongue movement, they may need time and experience to discover what their tongue can now do. Feeding itself provides repeated opportunities to practise, while additional tongue-function activities may sometimes help where a particular movement or skill needs more focused support. This means that there is no particular day on which we should expect feeding to suddenly become “perfect” simply because the wound has healed. Progress in feeding can continue after the wound looks completely healed, just as feeding difficulties do not necessarily mean that the wound has failed to heal. The two things need to be considered separately. Your baby's tongue should therefore be assessed by function rather than by the appearance of the wound or by whether the wound has reached a particular stage of healing. What might tongue-strengthening exercises look like? There is no single set of exercises that every baby needs. Depending on the baby's age, feeding method, oral skills and individual assessment, activities might involve encouraging the tongue to move forwards or sideways, supporting cupping or tongue elevation, encouraging an appropriate response to touch around the lips and mouth, or using feeding itself as an opportunity to practise more effective tongue movement. For some babies, ordinary feeding may provide all the practice they need. For others, additional activities may be useful for a period of time. The important point is that these activities should have a purpose. There is little value in giving a long list of exercises simply because a tongue-tie has been divided. If a particular movement or feeding skill is already working well, repeatedly practising it may not add anything useful. Equally, if a baby is struggling with a particular aspect of tongue function, targeted activities may help provide additional opportunities to practise that movement. This is why an individualised approach rather than a fixed routine that every baby is expected to complete is good practice. Your baby's feeding gives important information After a frenulotomy, it can be tempting to focus entirely on what the tongue looks like underneath the mouth. Feeding tells us much more. A useful follow-up considers things such as how the baby is attaching, whether they can maintain a seal, how effectively they are transferring milk, whether they fatigue during feeds, whether they cough or splutter, whether they repeatedly lose their seal and how comfortable and settled feeding appears to be. Breast and bottle feeding also place slightly different demands on the feeding system, so the assessment needs to reflect how your baby actually feeds. If feeding is improving, that is useful information. If feeding remains difficult, it does not necessarily mean that more exercises are needed. It may mean that the feeding picture needs to be reassessed. The tongue does not function in isolation The tongue is only one part of a much larger system involved in feeding. The jaw, lips, cheeks, palate, head, neck and wider body all contribute to how a baby positions themselves and coordinates sucking, swallowing and breathing. There is a growing and substantial body of research exploring manual and osteopathic approaches in relation to infant feeding. Studies have investigated areas including latch, sucking ability and other feeding-related outcomes, and recent reviews have brought together a much larger body of literature than was available a few years ago (Hawk et al., 2018; O'Connell et al., 2026). The research is varied in its methods and quality, and not every study has demonstrated a feeding benefit. For example, a randomised controlled trial of osteopathic treatment in breastfed infants did not find an improvement in exclusive breastfeeding at one month (Jouhier et al., 2021), while other studies have reported improvements in measures of latch or sucking (Hafer et al., 2017; Fons et al., 2025). Taken together, this means that body-based approaches are an area of active research rather than something that should be dismissed as having no evidence behind it. They may be considered alongside feeding support where an individual assessment suggests that wider physical factors could be contributing to feeding difficulties. Body-based approaches should therefore be considered as an individualised adjunct where there is a reason to consider them, rather than as an automatic part of every tongue-tie release. Birth can also be part of the wider picture A baby's birth and early experiences may be relevant when considering movement, comfort and feeding. Assisted births, prolonged or difficult labours, different birth positions and caesarean birth can all form part of the history that a practitioner considers when looking at the feeding dyad. This recognises that babies arrive at feeding with their own individual experiences of birth, movement and early adaptation, and that these may sometimes be relevant to the wider functional picture. For example, recovery following a caesarean birth can also affect the practical experience of establishing breastfeeding in the early days (Beake et al., 2017). Feeding is still the main event The purpose of improving tongue movement is to support function, particularly feeding. Feeding provides repeated opportunities for your baby to use their tongue, jaw, lips and wider body together. Additional exercises can sometimes provide more focused practice where a particular area needs support, but they are not a replacement for looking at the whole feeding picture. A wound can heal while feeding skills are still developing, and feeding can continue to change as your baby becomes stronger, more coordinated and more confident in using their tongue. For some babies, feeding will gradually become easier as they become accustomed to their new range of movement. Others may benefit from more specific support with tongue function, feeding technique or wider physical factors. There is no single point at which healing, tongue function and feeding development all arrive at the same destination. They are separate but connected parts of the same journey. References Association of Tongue-tie Practitioners (ATP) (2022) ‘Position statement: Infant frenulotomy’. Available at: https://www.tongue-tie.org.uk/position-statements Beake, S., Bick, D., Narracott, C. and Chang, Y-S. (2017) ‘Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: a systematic review’, Maternal & Child Nutrition, 13(4), e12390. Available at: https://doi.org/10.1111/mcn.12390 Griffin, M.F. et al. (2022) ‘Understanding scarring in the oral mucosa’, Advances in Wound Care, 11(10), pp. 537–547. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9347381/ Hafer, R. et al. (2017) [study of osteopathic treatment and breastfeeding-related outcomes]. Hawk, C., Minkalis, A., Webb, C., Hogan, O. and Vallone, S. (2018) ‘Manual interventions for musculoskeletal factors in infants with suboptimal breastfeeding: a scoping review’, Journal of Evidence-Based Integrative Medicine, 23. Available at: https://doi.org/10.1177/2515690X18754391 Jouhier, A. et al. (2021) [randomised controlled trial of osteopathic treatment in breastfed infants]. Miller, A. et al. (2025) ‘Postoperative stretching after frenotomy for ankyloglossia and recurrent tongue-tie’. Available at: https://pubmed.ncbi.nlm.nih.gov/40010205/ O'Connell et al. (2026) ‘Osteopathic Manipulative Treatment for the Breastfeeding Dyad: A Scoping Review’, Journal of Human Lactation. Wong, J.W. et al. (2009) [study of oral mucosal wound healing]. Available at: https://pubmed.ncbi.nlm.nih.gov/19769724/

There is no single breastfeeding position that every caregiver and baby needs to use, and you may find you change the way you hold your baby throughout your feeding journey for all sorts of reasons. A position that felt comfortable when your baby was newborn may not feel quite so practical a few months later, while a position you initially struggled with may become your favourite once your baby is bigger and more confident at the breast. You may have been shown a particular position in hospital or by a midwife or breastfeeding supporter, only to discover that it does not feel quite the same when you are sitting on your own sofa at 3am. That does not mean you are doing it wrong. Breastfeeding positions are not fixed techniques that have to be reproduced exactly. They are different ways of arranging your bodies so that your baby can come comfortably to the breast and you can sustain the feed. The important thing is not whether your baby looks as though they are in a particular "correct" position. What matters is whether you are comfortable, your baby can attach well and feeding is working for you both. Start with positioning before thinking about the latch Positioning and attachment are closely connected, but they are not quite the same thing. Positioning is about how you arrange yourself and your baby in relation to the breast, while attachment describes how your baby takes the breast into their mouth. A baby can appear to be in a good position but still attach shallowly or uncomfortably. Equally, changing the way you position your baby can sometimes make it much easier for them to achieve a deeper and more comfortable attachment. Before thinking about exactly where your baby's mouth should go, it is worth considering your own position too. You need to be comfortable enough to remain there for the duration of the feed. Supporting your back, arms or feet can make a considerable difference, particularly during long or frequent feeds. The aim is not to hold your baby in a particular pose but to create an arrangement in which your baby can come close to the breast without you having to lean forwards, twist or hold their weight entirely with your arms. For more about the principles of attachment and getting a deeper latch, see How to improve infant latch: practical breastfeeding support. Your baby's whole body matters It is easy to focus on the baby's mouth because that is where the latch happens, but the rest of the body matters too. Your baby's chest and tummy will generally be facing towards you, with their body close enough to the breast that they do not have to stretch or twist to reach it. Their head, neck and body should be reasonably well aligned rather than their head being turned towards the breast while their body faces somewhere else. A useful principle is to think about your baby's ear, shoulder and hip being in a straight line. This does not mean that your baby has to look rigid or perfectly symmetrical. Babies move, and different positions will naturally alter the angle of their body. The important point is that they are not twisted through the neck or body while trying to feed. You may also come across the memory aid CHINS: Close Head free In line Nose to nipple Sustainable CHINS is a useful way of remembering the underlying principles, rather than a requirement for your baby to look exactly the same at every feed. Research into CHINS has also explored how families experience using it as a breastfeeding memory aid, with participants describing it as useful particularly during the early stages of breastfeeding (Shotton and Collins, 2024). How your baby comes onto the breast The way your baby approaches the breast is important. Rather than bringing your baby's face directly towards the nipple as though the nipple were a target, your baby's head can be allowed to tip back as their mouth opens. Think about what happens when someone takes a large drink from a glass. They do not usually bring the glass directly towards the centre of their mouth while keeping their head completely still. As they take a larger drink, the head tilts back, the mouth opens and the drink enters the mouth from above. The same principle can help explain what happens when a baby comes onto the breast. Your baby's nose is level with the nipple, but their head is angled upwards, as though they are looking or pointing upwards towards your forehead. This creates the angle needed for the mouth to open widely while the chin comes towards the breast. As your baby's mouth opens, the lower jaw moves while the upper part of the skull remains relatively still. The breast itself is also not weightless. As the breast rests against the baby's chin, its weight can help the chin move downwards and encourage the lower jaw to take a greater mouthful of breast tissue. This means that the lower part of the attachment can contain more breast tissue, rather than the baby simply taking the nipple into the centre of the mouth. The breast is effectively coming up and over into the open mouth, with more tissue being taken into the mouth on the underside of the latch. In simple terms, think of it as nose to nipple, head angled upwards, mouth opens, chin leads and the breast goes up and over into the mouth. This is different from trying to line the nipple up with the centre of your baby's mouth like a bulls-eye and bringing the baby's face directly forwards onto it. The aim is for your baby to take a larger mouthful of breast tissue rather than attaching primarily to the nipple. Allowing the head to tip back also means you should avoid pushing the back of your baby's head forwards towards the breast. Your baby's head needs to be free enough to move as they open their mouth and attach. An asymmetrical latch A comfortable and effective attachment does not necessarily mean that the nipple sits in the exact centre of your baby's mouth. With an asymmetrical attachment, the nipple enters the mouth at an angle and the baby takes more breast tissue into the lower part of the mouth. This fits with the wider principle of allowing the chin to lead and the baby to take a larger mouthful of breast rather than simply attaching to the nipple itself. You may also notice that there is more of the darker nipple and areola skin visible above your baby's upper lip than below their lower lip. NHS guidance describes this as one of the signs that can be seen with effective attachment (NHS, 2026). It is important not to turn this into another "perfect latch" test, though. Areolas vary considerably in size, shape, colour and symmetry. Someone with a very large areola will naturally have a different visual appearance from someone with a small one, and the amount of visible areola may also be affected by individual breast anatomy. The marker is therefore most useful when considered alongside how the feeding feels, how your baby is feeding and what the attachment actually looks and feels like. The 'Flipple' technique The 'flipple' technique is a way of changing the starting angle of the nipple so that it is directed upwards towards the roof of the baby's mouth rather than forwards into the centre of the mouth. The term 'flipple' is used in breastfeeding support to describe this particular approach, but the named technique itself has limited specific research. The underlying principles are more established: starting with the baby's nose level with the nipple, allowing the head to tip back, waiting for a wide gape, bringing the chin to the breast first and allowing the nipple to enter the mouth towards the roof rather than aiming it straight forwards (NHS, 2026). To use the technique, start with your baby's nose level with your nipple and their head angled upwards towards your forehead. Support your breast so that the nipple is angled upwards. As your baby opens their mouth wide and brings their chin towards the breast, release the finger or thumb that was supporting the upper surface of the breast while continuing to support underneath. This allows the breast and nipple to move further into your baby's mouth. As the baby's mouth closes around the breast, their suction or vacuum can help draw the nipple further back towards the soft palate. The "flip" is therefore not about putting the nipple into your baby's mouth like a target. It changes the starting angle and allows your baby's gape, chin-first approach and suction to bring the breast further into the mouth. Breastfeeding should be comfortable A position can look technically good and still not be comfortable for you. There is no benefit in maintaining a position simply because someone has told you that it is the "right" one if your shoulders are aching, your back is strained or your baby's attachment is painful. This is one reason why the final part of CHINS is sustainable. A breastfeeding position needs to be something that you can actually maintain, particularly when feeds are frequent or long. Some initial tenderness can occur when breastfeeding is being established, but persistent or significant pain deserves attention rather than simply being accepted as part of breastfeeding. Persistent nipple or breast pain can have a number of possible causes, and the Academy of Breastfeeding Medicine recommends assessing the feeding dyad when pain persists rather than assuming that one explanation applies to everyone (Berens et al., 2016). For more about painful attachment, see Painful breastfeeding latch: support that helps. What if you have larger breasts? Breast size can influence which positions feel comfortable and how much support you need. This is not because there is a particular position that people with larger breasts are supposed to use, but because the breast itself may need more support while your baby comes to the breast. Some caregivers find a sandwich hold helpful, where the breast is gently compressed to make it easier for the baby to take a larger mouthful. A scissor hold, using the fingers to support the breast, is another option that some people find useful. Neither hold is compulsory. If your baby is attaching comfortably without you holding the breast, there is no reason to add another hand or another technique simply because you have been told you should. The shape and size of the breast can also mean that you need to position your baby slightly differently on one side compared with the other. Breasts are not necessarily identical, and there is nothing unusual about finding that one side works better with a slightly different arrangement. What about milk supply? Positioning is only one part of breastfeeding and should not be treated as a complete explanation for milk supply. Effective milk removal can influence milk production, so a comfortable attachment that allows your baby to transfer milk effectively can be relevant to supply. However, milk production and milk transfer are influenced by many factors, and concerns about supply need to be considered in the wider feeding picture rather than assuming that changing position will solve the problem. UNICEF UK Baby Friendly guidance includes positioning, attachment, milk production and milk transfer as related but distinct parts of assessing breastfeeding (UNICEF UK Baby Friendly Initiative, 2013). Different breastfeeding positions There are many named breastfeeding positions, but you do not need to learn all of them. They are simply different ways of arranging your bodies, and some will suit you better at particular times than others. The positions described below are examples rather than a list of positions that you need to learn. In fact, you can make up your own position if it is comfortable and effective for your feeding dyad. The names given to breastfeeding positions are useful for describing familiar arrangements, but babies and breasts do not always fit neatly into named categories. As long as your baby is well supported, their ear, shoulder and hip remain appropriately aligned, their head and neck are free to move, and they can come onto the breast comfortably and feed effectively, there is plenty of scope to experiment. In essence, if a baby wanted to feed upside down and both of you could safely and comfortably maintain the position, there is no breastfeeding rule that says the position has to have a particular name. The important principles are more useful than the label. Cradle hold The cradle hold is one of the positions many people recognise immediately. Your baby's body lies across your lap, with their head supported by the arm on the same side as the breast they are feeding from. It can be comfortable once you and your baby are confident with breastfeeding, particularly when your baby has good head and body control. However, it is not necessarily the easiest position for a newborn who is still learning to attach because it can be harder to control the baby's approach to the breast. Supporting your own arms and back can make a big difference. You should not need to lean forwards to keep your baby's mouth at the breast. Cross-cradle hold In the cross-cradle position, your baby lies across your body as in the cradle hold, but you use the opposite arm to support and guide your baby's body. This gives you more control over your baby's position and can be particularly useful while you are learning what helps your baby attach comfortably. It can also make it easier to see what your baby's mouth is doing as they come onto the breast. Once your baby is well attached, you may find that you can gradually relax your hold rather than continuing to actively control the feed. Rugby or football hold In the rugby or football position, your baby is tucked alongside your body rather than lying across the front of your tummy. Their legs point behind you and their head is positioned near the breast. Some people find this particularly useful after a caesarean birth because the baby's body does not need to rest across the abdomen. It can also be useful if you have larger breasts, if you want a different angle on the breast or when feeding twins. The NHS includes the rugby hold among its commonly used breastfeeding positions (NHS, 2026). Laid-back or reclined breastfeeding Laid-back breastfeeding is different from simply sitting slightly backwards while your baby lies beside you. In a true laid-back position, you are comfortably reclined and your baby is really lying against you, with their body supported on your body rather than simply being placed on their side next to you. Your baby's tummy can rest against your tummy or chest, with their body supported by yours. This can allow your baby to make use of their own movements and can be particularly useful when you want to give them more freedom to approach the breast. Research into laid-back breastfeeding has found associations with reduced nipple pain and trauma and improved positioning and attachment compared with some traditional positions, although the evidence has limitations and further research is needed (Wang et al., 2021). If you are very tired or there is any possibility that you may fall asleep, however, breastfeeding and sleeping are separate considerations. Sofas and armchairs are particularly unsafe places to fall asleep with a baby. The Lullaby Trust provides specific safer-sleep guidance for situations where feeding occurs in bed and for avoiding accidental sleep on sofas or chairs (The Lullaby Trust, 2026). Side-lying Side-lying can be particularly useful for night-time feeds or when sitting upright is uncomfortable. You and your baby lie facing one another, with your baby close enough to reach the breast without needing to twist their neck. The ear, shoulder and hip alignment remains useful here too. Your baby should not need to turn their head sharply towards the breast while their body faces the other direction. Side-lying can be comfortable for feeding, but it is important to distinguish feeding from sleep. If there is any chance you may fall asleep, consider the safer-sleep guidance for bed sharing and make sure you understand when bed sharing is not recommended. Never intentionally fall asleep with a baby on a sofa or armchair (The Lullaby Trust, 2026). Koala / Saddle position In a koala or saddle hold position, your baby is sitting more upright against your body rather than lying horizontally across your lap. This can work particularly well as babies become more capable of sitting with support and may suit babies who dislike being held horizontally for every feed. It can also be useful when a baby wants to remain more upright between or during feeds. There is no need to wait for a particular age before experimenting with a more upright position, provided your baby is properly supported and can feed comfortably. The seatbelt position The seatbelt position is a variation in which the baby sits more upright across your body, with their body and legs extending towards the opposite side, rather like a seatbelt crossing your torso. It can provide a useful alternative for an older baby who is becoming more mobile and no longer wants to remain in a traditional cradle position. As babies become stronger and more curious, you may find that the named positions become less useful than simply finding a stable arrangement that allows them to reach the breast comfortably. Dancer hold The dancer hold is a breastfeeding technique that provides additional support beneath a baby’s jaw while they feed. The baby is positioned facing the breast, with their body supported under the caregiver’s arm in a semi-reclined or football/rugby-style position, although the technique can be adapted to other breastfeeding positions. The caregiver supports the breast with one hand while using the thumb and fingers of the same hand to form a gentle U-shape beneath the baby’s cheeks and jaw. This can be particularly helpful for babies with low muscle tone, a less stable jaw, or difficulty maintaining a deep latch, as the additional support can help them maintain their position and sustain their latch during the feed. Older babies Breastfeeding positions often become much less formal as babies grow. A baby who once needed to be carefully supported across your lap may eventually climb onto you, kneel beside you, sit across your thigh or feed while you are both lying down. Older babies may also move around considerably during a feed, particularly if they are distracted or interested in what is happening around them. This does not necessarily mean that the attachment is poor. Development changes the way babies use their bodies, and the position that worked for a newborn may simply no longer be necessary. Twins and higher-order multiples With twins or higher-order multiples, feeding at the same time can be practical for some families, but it is not essential. Many babies in a multiple birth do not want to feed at the same time, particularly as they grow and develop their own feeding patterns. Feeding each baby separately is perfectly possible, and families can use a mixture of simultaneous and individual feeds depending on what works for them. The rugby or football position is often used when feeding twins simultaneously because it allows one baby to be positioned on each side of the body, but other combinations are possible too. The NHS specifically notes that trying different breastfeeding positions can help families find what suits them best when feeding twins or multiples (NHS, 2026). Changing position during a feed There is no reason to remain in one position for an entire feed if another position becomes more comfortable or seems to work better as the feed progresses. Your baby may change their own position as they become more relaxed, as milk flow changes or as the breast becomes softer, and you may find that your own body needs a different level of support after sitting in the same position for a while. Some feeding dyads naturally move between positions during a feed, while others find one position that remains comfortable from beginning to end. You may even find that one breast feels easier in one position and the other breast in another. As babies grow, their preferences can change too, so the position that worked when your baby was two weeks old may not be the position they choose at six months. Breastfeeding does not need to look the same every time, and there is nothing wrong with changing position simply because you and your baby prefer something different. If, however, you find yourself repeatedly changing positions because your baby cannot maintain the latch, feeding remains painful, your baby is struggling to transfer milk or feeds are becoming increasingly difficult, that is different from simply experimenting with positions. At that point, rather than continuing to try one position after another, it would be appropriate to have the feeding observed and evaluated by someone suitably qualified to assess breastfeeding and infant feeding. When changing position does not solve the problem Positioning can make a substantial difference, but it cannot explain or resolve every breastfeeding difficulty. If your baby repeatedly slips from the breast, you are experiencing persistent pain or nipple damage, feeds are exhausting, or there are concerns about milk transfer, milk production or your baby's growth, the feeding picture needs to be considered more broadly. A skilled feeding assessment should look at what is actually happening during the feed rather than simply matching a symptom to a particular position or anatomical finding. This may include your baby's attachment and milk transfer, your comfort, breast or nipple factors, milk production and flow, your baby's health and development, oral function and the interaction between all of these factors. This is where having a feed observed by someone appropriately qualified can be much more useful than being given another list of positions to try. The aim is to understand why feeding is difficult for this particular dyad and whether a change in position is actually likely to help. Persistent pain, repeated loss of attachment or concerns about feeding effectiveness therefore deserve a proper breastfeeding evaluation rather than an expectation that you should simply keep experimenting until you find the "right" position. The position that works is the one that works for you There is no prize for making breastfeeding look like the picture in a leaflet. The best position for you may change from feed to feed, breast to breast, day to day and as your baby grows. You may use a traditional cradle hold one day, feed lying down the next, discover that your baby prefers to feed upright for a while, or end up inventing something that does not have a name at all. The useful principles are simple: you and your baby need to be comfortable, your baby needs to be close and well supported, their body should be appropriately aligned, their head should be free to move and they should be able to open their mouth and come onto the breast comfortably. Breastfeeding positions are there to give you options, not rules. The position that works is the one that allows you and your baby to feed comfortably, effectively and sustainably. References Berens, P., Eglash, A., Malloy, M. and 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. NHS (2026) ‘Breastfeeding: positioning and attachment’. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/positioning-and-attachment/ NHS (2026) ‘Breastfeeding positions’. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/how-to-breastfeed/breastfeeding-positions/ NHS (2026) ‘Feeding twins and multiples’. Available at: https://www.nhs.uk/baby/newborn-twins-and-multiples/feeding-twins-and-multiples/ Shotton, L. and Collins, T. (2024) ‘Breastfeeding mothers’ awareness and experience of using the breastfeeding memory aide CHINS: an exploratory descriptive qualitative study’, Reproductive, Female and Child Health, 3, e108. doi:10.1002/rfc2.108. The Lullaby Trust (2026) ‘Co-sleeping’. Available at: https://www.lullabytrust.org.uk/baby-safety/safer-sleep-information/co-sleeping/ UNICEF UK Baby Friendly Initiative (2013) ‘The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards’. London: UNICEF UK. UNICEF UK Baby Friendly Initiative (2020) ‘Supporting effective breastfeeding: CHIN principles’. London: UNICEF UK Baby Friendly Initiative. Wang, Z., Liu, Q., Min, L. and Mao, X. (2021) ‘The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis’, BMC Pregnancy and Childbirth, 21, 248. doi:10.1186/s12884-021-03714-8.

Feeding difficulties can look very different from one baby to another. A baby may have very short and frequent feeds, feed for a long time, repeatedly slip off the breast, become unsettled during feeds, or leave a caregiver experiencing ongoing pain. Bottle-feeding families may notice tiring or prolonged feeds, milk leaking, clicking, coughing, difficulty maintaining a comfortable seal or a baby who seems to struggle to coordinate feeding. These experiences can occur with breastfeeding, bottle feeding or combination feeding, and the same underlying factor does not necessarily explain every feeding difficulty. When feeding isn't going well, it can be tempting to look for one explanation. If a frenulum is noticed under the baby's tongue, tongue-tie may quickly become part of that conversation. Sometimes restricted tongue function is relevant to feeding, while at other times another factor may be contributing, or several things may be happening together. Looking beyond tongue-tie does not mean dismissing it. It means making sure that the whole feeding picture is considered. A feeding difficulty is not a diagnosis A feeding difficulty describes what is happening; it does not, by itself, tell us why it is happening. A baby who feeds for a long time may be experiencing difficulty maintaining an effective seal, but long feeds can also occur for other reasons. A baby who feeds very frequently may have difficulty transferring milk, but frequent feeding can also be completely appropriate at certain stages of infancy. Clicking can occur with changes in positioning or attachment, milk flow, oral coordination or other factors, and not every baby who clicks has a tongue-tie. The same applies to bottle feeding. Dribbling, coughing, milk loss, tiring, prolonged feeds or difficulty maintaining a seal may have several possible explanations. This is why a feeding assessment needs to look beyond a single symptom or a single anatomical finding. The current UK Infant Feeding Survey found that feeding difficulties are varied, with mothers reporting problems including reflux, colic or wind, breast or nipple discomfort, difficulty with latching, milk supply concerns, positioning difficulties and bottle-feeding difficulties. There are many possible contributors There are far more possible contributors to feeding difficulties than can reasonably be listed in one article, so the examples below are intended to illustrate the breadth of the feeding picture rather than provide an exhaustive list. Some factors may be temporary. Others may have been present from the beginning. Some may affect feeding directly, while others may influence how a baby approaches feeding or how easily they can coordinate the different movements involved. And sometimes more than one factor is present. Positioning and attachment For breastfeeding, positioning and attachment can make a substantial difference to how comfortably and effectively a baby feeds. A baby may appear to be attached while still having a shallow or unstable attachment, and this can contribute to nipple pain, slipping on and off the breast, clicking or concerns about milk transfer. Breastfeeding is also different from simply feeding from a nipple. The aim is not for a baby to draw only the nipple into the mouth in the way a bottle teat is drawn into the mouth. Effective breastfeeding involves a deeper attachment to the breast tissue, with the nipple drawn into the baby's mouth as part of that attachment. This distinction matters because nipple shape alone does not determine whether breastfeeding will be successful. Babies can breastfeed effectively with inverted or less prominent nipples when they are able to attach well to the breast. If positioning or attachment is difficult, this does not mean that tongue-tie is necessarily responsible. Equally, improving positioning and attachment does not rule out the possibility that restricted tongue function may also be contributing. A skilled feeding assessment can help separate these possibilities rather than assuming that one explains everything. Milk flow Milk flow can influence how a baby feeds. A very fast milk flow may leave a baby struggling to coordinate sucking, swallowing and breathing, while a slower flow may require a different feeding pattern. Changes in milk supply can also alter the way a baby behaves at the breast. For breastfeeding families, milk transfer and milk production are related but are not the same thing. A concern about supply therefore deserves consideration of the whole feeding pattern rather than automatically being attributed to tongue-tie. The NHS identifies positioning and attachment, feeding frequency, maternal and infant illness and several other factors as possible influences on milk supply, alongside restricted tongue movement in some babies. Maternal anatomy and feeding mechanics Maternal anatomy can form part of the feeding picture, but it is important not to suggest that a particular breast or nipple shape is inherently a problem. Nipple pain, nipple trauma or a nipple that appears misshapen after a feed may be useful clues that the feeding mechanics are worth exploring. They do not, however, mean that the shape of the nipple itself is causing the difficulty. Successful breastfeeding does not depend on having a particular nipple shape. What matters is how the baby attaches and feeds at the breast. This is another reason why looking at the feeding interaction itself can be more informative than focusing on one physical feature in isolation. Feeding coordination and developmental maturity Feeding requires considerable coordination. A baby has to organise sucking, swallowing and breathing while maintaining an effective seal and responding to the flow of milk. These skills develop and mature over time, and they can be influenced by gestational age, birth history, illness, neurological development, muscle tone and the baby's state at the time of feeding. A baby who was born prematurely, for example, may have very different feeding skills from a baby of the same chronological age who was born at term. Developmental maturity therefore needs to be considered alongside the feeding difficulty rather than assuming that every difficulty is caused by an anatomical restriction. Nasal congestion and breathing Babies need to coordinate breathing with feeding, and nasal congestion can make this more difficult. A blocked or congested nose may cause a baby to pause frequently, pull away from the breast or bottle, become unsettled, feed for shorter periods or tire more easily. Respiratory illness can temporarily change feeding even when oral function has not changed. If a baby is struggling to breathe comfortably during feeding, this needs appropriate assessment rather than being assumed to be a tongue-tie problem. Teething and changes in the mouth Teething can temporarily change feeding because a baby's gums and mouth may feel uncomfortable. During effective breastfeeding, the tongue should extend forwards over the lower gumline, helping to protect the breast from direct contact with the lower teeth. When a baby is well attached and feeding effectively, the caregiver should not normally feel the teeth during active feeding (Guóth-Gumberger, 2026). Teething can nevertheless make the baby's mouth sore, particularly when they are not actively feeding, and this may temporarily alter how readily they approach the breast or how they behave during feeds. The presence of teeth therefore does not automatically explain nipple pain or biting during breastfeeding. If feeding has become uncomfortable, the attachment and mechanics of the feed are worth reviewing. Illness and other medical factors Babies may feed differently when they are unwell. Even a relatively short-lived illness can affect appetite, alertness, breathing, stamina or willingness to feed. There can also be medical factors that are much more important to recognise. For example, a heart murmur should never simply be dismissed as an innocent explanation for feeding difficulties. Many babies with heart murmurs do have normal hearts, but a murmur can sometimes be associated with an underlying heart problem, which is why babies with murmurs are assessed and, where necessary, followed up. If a baby with a heart murmur is feeding poorly, becoming breathless or unusually sweaty during feeds, tiring markedly, failing to gain weight as expected, breathing unusually quickly, working harder to breathe, or developing pale, blue or mottled skin, these symptoms need medical assessment rather than being attributed to oral function. NHS guidance for families specifically advises urgent assessment when a baby with a murmur becomes unwell or develops these warning signs. These symptoms can have causes other than heart disease, but that is precisely why they need appropriate clinical assessment. Changes following routine immunisations Some babies are temporarily more sleepy, unsettled or uncomfortable following routine immunisations, and feeding may change for a short period as a result. Breastfeeding can also provide comfort during vaccination, with evidence that breastfeeding around vaccination can reduce crying and behavioural measures of pain in infants (Harrison et al., 2016). A temporary change in feeding following an immunisation does not necessarily indicate a new problem with oral function. Routine immunisations should not be delayed simply because a baby may temporarily feed differently. If a baby is significantly unwell following an immunisation, or a caregiver is concerned about their symptoms, appropriate medical advice should be sought. Learned compensations Sometimes a baby has experienced feeding difficulty for long enough that they develop learned compensations. A baby may find another way to maintain a seal, alter the way they use their jaw, change their tongue position, take frequent pauses or develop a particular feeding pattern that allows them to manage as well as they can. These compensations are not simply a matter of behaviour. They can become part of the baby's established feeding pattern. If the original contributing factor changes, the learned compensation may not disappear immediately. This is one reason why feeding may remain difficult even when an underlying problem has been addressed. It also means that continuing feeding difficulties do not automatically prove that a tongue-tie remains the problem, or that another procedure is required. The feeding pattern needs to be reassessed in its own right. Feeding frequency does not tell the whole story The number of feeds or the length of individual feeds can sometimes provide useful information, but neither measure can tell us on its own whether feeding is effective. Some babies naturally feed quickly. Others take longer. Some feed frequently because they are establishing milk production or going through a period of increased demand. Others may feed frequently because they are not transferring milk efficiently or are tiring during feeds. The same principle applies to bottle feeding. A baby who takes a long time to finish a bottle may be tired, poorly coordinated, affected by the flow rate, uncomfortable or experiencing another difficulty. A baby who takes very small amounts frequently may have a completely different reason for doing so. The pattern needs to be considered alongside the baby's behaviour, intake, growth, output, comfort and overall wellbeing. Sometimes several things are happening at once This is perhaps one of the most important reasons not to search for a single explanation. A baby may have nasal congestion at the same time as a fast milk flow. A caregiver may be experiencing nipple pain alongside positioning difficulties. A baby may be recovering from an illness while also becoming more unsettled because of disrupted sleep. A change in feeding may occur during teething. A baby may have developed learned compensations following an earlier period of feeding difficulty. These examples are deliberately varied because feeding difficulties do not always come neatly packaged as one identifiable problem. Sometimes there is a tongue-tie as well. Sometimes there is not. The purpose of a careful assessment is therefore not to find a particular diagnosis to fit the symptoms, but to understand what is actually happening during feeding and which factors may be relevant to that individual baby and feeding dyad. What if a tongue-tie is suspected? If a tongue-tie is suspected, the next step should be a skilled assessment rather than assuming that the appearance of the frenulum explains the feeding difficulty. The important question is whether the frenulum is restricting tongue function and motility in a way that is relevant to feeding. A useful assessment therefore needs to consider more than whether a frenulum can be seen. It should explore the baby's history, feeding pattern, oral structures, tongue movement and function, and, where possible, observe feeding itself. The NHS also recognises that not every baby with tongue-tie has feeding problems, and that feeding difficulties can occur in both breastfed and bottle-fed babies. Where infant feeding is affected, it is particularly valuable for the assessment to include someone with substantial specialist infant-feeding knowledge. An International Board Certified Lactation Consultant (IBCLC) is the internationally recognised gold-standard credential in professional lactation care, with specific education, clinical experience and examination requirements. This is particularly important because the current evidence does not support treating the presence of a frenulum in isolation. The 2024 UK Infant Feeding Survey found that, among mothers reporting a diagnosed tongue-tie, 23% reported no feeding problems, while others reported breastfeeding, bottle-feeding or both being affected. A tongue-tie assessment should therefore answer a more useful question than simply “Does my baby have a tongue-tie?” It should help explore whether restricted tongue function is actually contributing to the feeding difficulty. You can read more about this in What Does a Tongue-Tie Assessment Consider? and Tongue-Tie Restriction in Babies (UK). If a tongue-tie is identified, treatment is not the only question Finding a tongue-tie does not automatically mean that a frenulotomy is required. The next question is whether the restriction is clinically relevant to the feeding difficulties being experienced and what options are available. For some babies and families, skilled feeding support and review may be sufficient. For others, persistent functional difficulties may lead to a discussion about frenulotomy. The decision needs to take account of the assessment findings, the baby's feeding, the potential benefits and limitations of treatment, the risks of the procedure and the family's own circumstances and priorities. You can explore these decisions in more detail in Surgical Release or Conservative Management for My Baby's Tongue-Tie. If a frenulotomy is being considered, families may also want to understand the procedure itself, the different methods used, the evidence and the possible risks. Those questions are explored separately in What a Frenotomy Procedure Means for Your Baby and Frenulotomy Methods in Infants: What Matters?. Aftercare and feeding support also deserve their own consideration. A frenulotomy addresses a restrictive frenulum; it does not automatically resolve every contributor to feeding difficulty, particularly where a baby has already developed compensatory feeding patterns. Beyond the Tongue-Tie Release: Why Aftercare Matters explores why feeding support continues to matter after the procedure. When should feeding difficulties be reviewed? Persistent feeding difficulty deserves attention whether or not a tongue-tie is visible. It is particularly important to seek appropriate help if feeding is painful, exhausting, increasingly difficult, associated with concerns about intake or weight gain, or if a baby is regularly coughing, choking, becoming breathless, tiring excessively or appearing distressed during feeds. Medical assessment is important when feeding changes occur alongside signs of illness, breathing difficulty, poor weight gain, unusual lethargy, colour change or other symptoms that suggest the baby may be unwell. A tongue-tie assessment may be appropriate when restricted tongue movement is suspected, but it should not replace medical assessment where a baby's symptoms could have another cause. Looking at the whole feeding picture There is no single sign that can tell a family why feeding is difficult. A baby may have a tongue-tie and feed well. A baby may have significant feeding difficulties without a tongue-tie. Another baby may have restricted tongue function alongside several other factors that are affecting feeding at the same time. The most useful starting point is therefore the baby in front of you and the feeding that is actually happening. That means considering how the baby attaches or maintains a seal, how milk is flowing, how sucking, swallowing and breathing are coordinated, how comfortable feeding is, how the baby is growing and behaving, whether there are signs of illness or other medical concerns, and whether established feeding patterns or learned compensations may now be contributing. Looking beyond tongue-tie is not about ruling tongue-tie out. It is about making sure that a visible frenulum does not become the explanation before the feeding difficulty itself has been properly understood. Anatomy provides information. Function provides context. References Guóth-Gumberger, M. (2026) ‘Implications of the tongue's anatomy and biomechanics for breastfeeding’, Acta Paediatrica. doi: 10.1111/apa.70555. Harrison, D., Reszel, J., Bueno, M., Sampson, M., Shah, V.S., Taddio, A., Larocque, L. and Turner, L. (2016) ‘Breastfeeding for procedural pain in infants beyond the neonatal period’, Cochrane Database of Systematic Reviews, 10, CD011248. doi: 10.1002/14651858.CD011248.pub2. Office for Health Improvement and Disparities (2026) Infant Feeding Survey in England 2024: Full report. London: Department of Health and Social Care. Available at: https://www.gov.uk/government/statistics/infant-feeding-survey-in-england-2024/infant-feeding-survey-2024-full-report (Accessed: 22 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. Thomas, J. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2024067605. doi: 10.1542/peds.2024-067605. NHS (2025) Congenital heart disease. Available at: https://www.nhs.uk/conditions/congenital-heart-disease/ (Accessed: 22 September 2026).

Expressing breastmilk can be a useful skill for many different reasons. Sometimes it is planned, such as returning to work or study. Sometimes it becomes necessary because a baby is premature, unwell, separated from their caregiver or not currently able to feed effectively at the breast. Expressing can also be part of a feeding plan when an infant needs additional milk to support weight gain, or when milk production needs to be increased or maintained. There is no single way to express and no single expressing routine that works for everyone. Hand expression, manual pumps and electric pumps can all be useful, and the best approach depends on why you are expressing, your baby's needs, your milk production and what is practical and sustainable for you. Expressing can also be hard work. It takes time, energy and organisation alongside caring for a baby. Looking after yourself is therefore part of the feeding plan too. Why might you need to express? There are many reasons why someone may express breastmilk, including: your baby is premature or unwell; your baby is temporarily unable to breastfeed effectively; you and your baby are separated; your baby is not transferring enough milk at the breast; your baby's weight gain needs additional support; you need to establish or increase milk production; you want to maintain milk production when a breastfeed is replaced; you are returning to work or study; you want someone else to be able to offer your baby expressed milk; you occasionally want to have some expressed milk available; your breasts are uncomfortably full; you have an oversupply and need to relieve discomfort without repeatedly emptying the breasts; you have been advised to express antenatally to collect colostrum. The reason matters because the way you express may need to be different depending on what you are trying to achieve. For example, expressing to increase milk production is different from expressing simply to relieve uncomfortable fullness. Expressing to provide additional milk for an infant who is struggling to gain weight is different again. The NHS advises that how often you express and how much you express should depend on why you are expressing (NHS, 2026a). Expressing to support infant weight gain Expressing may sometimes be recommended when an infant is not gaining weight as expected, has lost more weight than anticipated, or is not transferring enough milk during breastfeeding. The expressed milk can then be offered to the infant as additional milk while breastfeeding continues where possible. In this situation, expressing may have two purposes: to provide additional milk for the baby and, where appropriate, to maintain or increase milk production while the underlying feeding difficulty is being assessed. These are related, but they are not exactly the same goal. If an infant is struggling with weight gain, it is important to look at the whole feeding picture rather than automatically assuming that low weight means there is not enough milk being produced. Milk production, milk transfer, feeding effectiveness, the baby's health, feeding frequency and the amount of milk the baby is actually receiving all need to be considered. NICE recommends assessing feeding and considering appropriate support when faltering growth is identified (NICE, 2017). If your baby is not gaining weight as expected, seek appropriate feeding and clinical assessment rather than simply increasing expressing indefinitely. Expressing to establish or increase milk production Milk production is closely linked to milk removal. When milk is regularly and effectively removed, the breasts receive signals that milk is needed. If increasing milk production is the goal, expressing can therefore be used to provide additional stimulation and milk removal. For some people, this may involve expressing after breastfeeding. Double expressing after a feed can provide additional breast stimulation, and increasing the frequency of milk removal may also be useful when clinically appropriate. However, more expressing is not automatically better. If your baby is already feeding effectively and gaining weight well, repeatedly adding extra pumping sessions can sometimes create an oversupply. That can lead to persistent fullness, leaking, forceful milk ejection and recurrent breast inflammation. The aim should be to achieve the amount of milk that you and your baby need, rather than producing as much milk as possible. If you are considering expressing to increase milk production, it is worth understanding why production appears low in the first place. Positioning, attachment, milk transfer, feeding frequency, infant factors and maternal factors can all contribute. You can also read my article on Increasing Breast Milk Production. Expressing to maintain milk production If a breastfeed is being replaced by expressed milk and you want to maintain your existing level of milk production, expressing around the time that feed would normally have happened can help maintain regular milk removal. This is particularly relevant if someone else is giving your baby a bottle while you are apart, or if a breastfeed is temporarily not possible. If you are simply looking to maintain your milk production and are expressing after a feed, you may not need to keep expressing large additional volumes. Some people find that expressing from the breast their baby has just fed from until the flow has slowed considerably is enough to provide additional stimulation, but the appropriate approach varies between individuals. If your baby is not removing milk effectively, however, the answer may not be to keep adding more expressing. It may be more helpful to assess why milk removal is not effective. Expressing occasionally You do not have to express every day for expressing to be useful. You might want a small amount of milk available for someone else to offer your baby, to cover an occasional separation, for returning to work or study, or simply because you would like another feeding option available. Some people prefer hand expression for occasional use because it requires no equipment. Others find a manual or electric pump quicker or more convenient. There is no requirement to build a freezer full of milk unless that is something you actually want or need. Expressing when your baby is premature, unwell or unable to breastfeed For some families, expressing is necessary from the very beginning. A premature or unwell baby may not initially be able to breastfeed effectively. A baby may also be separated from their caregiver, admitted to neonatal care or temporarily unable to coordinate feeding. In these circumstances, expressing may be an essential way of providing human milk while also stimulating and maintaining milk production. This is one reason why the advice to simply “wait until breastfeeding is established before expressing” cannot apply to everyone. If expressing is clinically necessary, it may be needed from the first day. Neonatal units may also have their own guidance about expressing frequency, equipment, hygiene, transport and storage. Follow the guidance provided by your baby's clinical team. Expressing is not the answer to blocked ducts or mastitis If your breasts are inflamed, repeatedly pumping or expressing to try to “empty” the breast can remove more milk than your baby needs. That extra milk removal can stimulate further milk production and potentially create a cycle of increasing supply, fullness and inflammation. Current mastitis guidance recommends feeding according to your baby's needs and avoiding unnecessary additional milk removal. If you need to soften the breast because your baby cannot attach comfortably, expressing a small amount for comfort may be appropriate, but this is very different from repeatedly pumping to empty the breast (Breastfeeding Network, 2026). Cold therapy can help with swelling and discomfort. Warmth may feel soothing for some people or help milk to flow immediately before feeding, but prolonged or excessive heat can increase swelling and inflammation. Firm breast massage should also be avoided because it can cause additional tissue trauma. For more information, see my article on [blockages and mastitis care]. The important point is that if you have mastitis, the goal is not to keep removing more and more milk. Expressing with an oversupply Oversupply can make expressing a little more complicated because the aim is usually to find a balance between relieving discomfort and avoiding unnecessary additional milk removal. If your breasts are frequently very full between feeds, expressing a small amount for comfort can sometimes help you feel more comfortable while allowing your milk production to gradually regulate towards what your baby needs. It can be tempting to express until the breast feels completely soft, particularly when it feels very full or uncomfortable, but repeatedly removing larger volumes of milk can signal to your breasts that this amount of milk is needed. This can maintain or increase the oversupply and may contribute to a cycle of frequent fullness, leaking, forceful milk ejection and breast inflammation. Comfort expression therefore generally means removing enough milk to relieve the pressure rather than expressing until the breast is empty. If you are experiencing persistent oversupply, recurrent blocked areas, breast inflammation or significant discomfort, individualised breastfeeding support can help to identify what may be contributing to the oversupply and how milk removal can be gradually adjusted without making you more uncomfortable. Expressing during the first 4–6 weeks The first 4–6 weeks are an important time for your milk production to adjust to your baby's needs. During this period, your breasts are responding to how frequently and how effectively milk is removed, so adding extra milk removal can influence how much milk your body continues to produce. For this reason, if your baby is breastfeeding effectively, gaining weight appropriately and there is no clinical reason to express, routine expressing during the first 4–6 weeks is generally best avoided. This includes expressing simply to build a large freezer supply or routinely pumping after feeds when your baby is already feeding well. Removing additional milk tells your body that more milk is needed, which can contribute to oversupply. Oversupply can be uncomfortable and may result in very full breasts, leaking, forceful milk ejection and difficulties for your baby managing the flow. It can also contribute to recurrent breast inflammation and create a cycle in which you express to relieve fullness, only for your body to produce more milk in response. There are, however, many situations where expressing during these early weeks is clinically important and should not be avoided. Your baby may be premature, unwell, temporarily unable to breastfeed, separated from you, or unable to remove milk effectively. Expressing may be needed to provide your baby with additional milk, establish or maintain your milk production, or protect your milk supply while feeding difficulties are being addressed. If you need to express for a clinical reason, the frequency and amount will depend on your individual circumstances and may change as your baby becomes more effective at breastfeeding. An IBCLC can help you develop an individualised feeding and expressing plan that provides the milk your baby needs while avoiding unnecessary additional milk removal. It is also normal for your breasts to feel softer as breastfeeding becomes established. Softer breasts do not necessarily mean that your milk production is decreasing or that you do not have enough milk. Your baby's feeding, nappies, weight gain and overall wellbeing are more useful indicators than how full your breasts feel. Once breastfeeding is well established, you may decide that expressing is useful for occasional bottles, returning to work, sharing feeds or other reasons. There is no need to avoid expressing altogether; the aim during these early weeks is simply to avoid unnecessary additional milk removal while your milk production is establishing and your baby is learning to breastfeed. Antenatal hand expression Some pregnant women are advised to hand express colostrum before their baby is born so that small amounts of their first milk are available if needed after birth. Antenatal expression is generally discussed from around 36–37 weeks for pregnancies where it is considered appropriate. It is not suitable for everyone, however, so discuss it with your midwife or maternity team before starting. The reason for this caution is that expressing stimulates oxytocin release. Oxytocin is involved in milk ejection and also causes uterine contractions. If you are at increased risk of premature labour or have been advised not to express antenatally, follow your maternity team's advice. If you experience contractions while expressing before 37 weeks, stop and contact your maternity team for advice. The aim is not to collect a large volume. Colostrum is produced in small amounts and may come out as drops rather than a stream. Choosing how to express There are several ways to express breastmilk, and you may find that different methods suit different situations. Hand expression can be particularly useful for colostrum, occasional expression or when you do not have access to a pump, while a manual pump can be a convenient option when you want something portable and relatively simple to use. Electric pumps can be particularly useful when you are expressing frequently or need to express larger amounts. You can choose between single and double electric pumps depending on your circumstances. A single pump allows you to express one breast at a time, whereas a double pump allows both breasts to be expressed simultaneously. Double pumping can be useful when time is limited and, for some people, may provide additional stimulation to support milk production. There are also a growing number of wearable or in-bra pumps and hands-free pumping options. These can be particularly convenient if you need to move around while expressing, have other children to care for, are returning to work or simply find sitting beside a traditional pump difficult. They are not necessarily the best choice for every situation, however, and some people find that a traditional electric pump removes milk more effectively or comfortably. Some people use more than one method. For example, hand expression may be useful for collecting colostrum, a wearable pump might be convenient during the day, and a traditional double electric pump may be preferred when expressing regularly to establish or maintain milk production. The most expensive pump is not automatically the most appropriate one. Comfort, flange fit, effectiveness, portability, noise, cleaning, battery life and how frequently you need to express are all worth considering when choosing equipment. How to hand express Hand expression takes a little practice. At first, you may only see a few drops. Before you start: 1. Wash your hands. 2. Have a clean container ready. 3. Find somewhere comfortable. 4. Give yourself time rather than trying to rush. 5. If helpful, have your baby close by or look at a photograph, clothing or another reminder of your baby. 6. Some people find a warm drink, bath or shower helpful for relaxation and milk flow. Place your thumb above the breast and your fingers below it, forming a “C” shape around 2–3 cm back from the nipple. Gently press your fingers and thumb back towards the chest wall and then compress them together. Release and repeat rhythmically. Do not squeeze or pull the nipple itself, and do not slide your fingers across the skin. When the flow slows, move your fingers around the breast to a different position and repeat. You can alternate between breasts, returning to each breast more than once as the milk flow changes. The NHS provides further guidance on hand expression (NHS, 2026b). You can also read my guide to [hand expression]. What if the milk does not flow? It can be frustrating when you know there is milk available but the pump or your hands are producing very little. Try not to respond by immediately increasing the suction. Milk ejection is influenced by oxytocin, and feeling rushed, uncomfortable, watched or anxious can make it more difficult for some people to trigger a let-down. You could try taking a few slow breaths and consciously relaxing your shoulders and jaw. Having your baby close by, looking at a photograph or smelling a piece of your baby's clothing may also help some people. Gentle breast preparation, changing the position of the pump flange, returning to stimulation mode on an electric pump or changing the cycle speed or pattern can also be worth trying. Sometimes taking a short break and trying again a few minutes later is more productive than continuing to pump when nothing is happening. Switching breasts or finishing with some hand expression may also help. A warm shower or warm cloth may help some people with milk flow, although prolonged heat is not appropriate when the breast is inflamed. If you consistently struggle to express despite trying different approaches, it may be worth checking your flange fit, pump settings and the overall reason you are expressing. Using a manual breast pump Manual pumps are operated by hand and can be useful for occasional expression. They are relatively portable and do not require batteries or a power supply, which can make them useful when travelling or when you only need to express occasionally. Start gently and establish a rhythm that feels comfortable. As milk begins to flow, you can adjust your rhythm and change breasts when the flow slows. You do not need to squeeze the handle as hard as possible. More pressure does not automatically mean more milk, and excessive suction or pressure can make expressing uncomfortable. If your hand becomes tired or the pump is uncomfortable, it may be worth changing your position, taking a short break or considering whether another expressing method would suit you better. Using an electric breast pump Electric pumps can look complicated because they often have several settings. The exact terminology differs between manufacturers, but many pumps have a stimulation or let-down mode followed by an expression mode. Stimulation mode Stimulation mode is usually faster and gentler. Its purpose is to encourage the milk-ejection reflex. You may see this described as let-down, massage, stimulation or cycle mode depending on the pump. Once milk is flowing well, you can usually move into expression mode. Expression mode Expression mode generally uses a slower rhythm with stronger suction to remove milk. Start with the vacuum low and increase it gradually. The aim is the highest comfortable and effective setting, not the highest setting the pump can produce. If the suction hurts, your nipple is being pulled aggressively into the tunnel, your nipple blanches, the breast tissue is swelling or you notice rubbing or damage, reduce the suction and check the flange fit. Changing the pattern or cycle speed Some pumps allow you to change the speed or cycle rate. If milk flow slows significantly, you can try returning briefly to stimulation mode, changing the cycle speed or switching breasts before returning to expression mode. There is no single pump setting that is correct for everyone. Your breasts, nipples, milk production and response to the pump are individual, so it may take a little experimentation to find the combination that works comfortably and effectively for you. Flange fit matters The breast shield or flange is the part of the pump that sits over the nipple. A good fit allows the nipple to move freely within the tunnel without excessive rubbing or pulling in large amounts of surrounding tissue. A flange that is too small may cause rubbing, compression or nipple swelling, while a flange that is too large may draw excessive amounts of areola into the tunnel and may also be uncomfortable or less effective. The correct size can differ between breasts, and your size can also change over time. Your nipple should not be bruised, pinched or damaged by expressing. You can read more about this in my article Breast Pump Flange Fitting Assessment Explained. How long should you express? There is no universal length of time that everyone needs to express. How long you express will depend on why you are expressing, the age and needs of your baby, your milk production, the type of pump you are using, whether you are expressing one or both breasts and how effectively milk is being removed. If you are expressing instead of a breastfeed or expressing frequently to establish or maintain milk production, the overall frequency of milk removal is likely to be more important than trying to achieve a particular number of minutes at every session. If you are expressing for comfort, you may only need a short session to reduce the feeling of pressure, whereas someone expressing a complete feed may need considerably longer. Your own milk flow can also change during a session. You may notice that milk flows quickly at first, slows down, and then increases again after another let-down. Changing the pump settings, switching breasts or using hand expression at the end can sometimes help you make the most of these changes. If expressing is taking up a very large proportion of your day, it is worth reviewing the feeding plan rather than simply accepting that this is how things have to be. Expressing can be physically and mentally demanding, and a plan needs to be effective while also being realistic and sustainable for the person doing it. Sharing feeds with fathers, partners and other caregivers Expressed milk can allow a father, partner or another caregiver to take part in feeding. This can be meaningful for everyone involved, and it may be particularly useful when the breastfeeding caregiver needs to be away from their baby or wants another caregiver to participate in feeding. However, there is an important practical point that can sometimes get missed. If a partner gives a bottle instead of a breastfeed, the breastfeeding caregiver may still need to express around that time if they want to maintain milk production. The partner has taken over one part of feeding, but the breastfeeding caregiver may still be doing the physiological work of maintaining milk production. A bottle given by someone else therefore does not automatically create a break for the breastfeeding caregiver. Sometimes what is needed is genuine rest rather than another feeding task. A partner or family member may be able to take over settling the baby, changing nappies, preparing food, washing pump equipment, looking after older children or simply holding the baby while the breastfeeding caregiver sleeps or has a bath. Supporting the person who is feeding the baby is just as important as supporting the feeding itself. Looking after yourself while expressing Expressing milk can be exhausting, particularly when it is being fitted around frequent breastfeeding, caring for a baby and recovering from pregnancy and birth. Even when expressing is going well, it adds another task to an already busy day, and when you are expressing several times a day or around the clock, the cumulative physical and mental effort can be significant. Rest can therefore be an important part of your feeding plan. This is not always easy when you have a baby who wants to be held, fed or settled frequently, but accepting practical support when it is offered can make a real difference. If your partner, family member or friend can prepare a meal, bring you a drink, hold the baby while you shower or give you an opportunity to lie down, allowing them to help can give you some much-needed time to recover. It is also worth remembering that the housework does not need to take priority over you. There may be dishes, laundry or other jobs waiting to be done, but your physical recovery and emotional wellbeing are important too. Sometimes the most useful thing someone can do is take care of the household jobs while you rest with your baby. Looking after yourself does not have to mean finding large amounts of time. A bath or shower, sitting quietly with a cup of tea, having a nap, getting outside for a short walk or simply having someone else hold the baby while you have some uninterrupted time can all be valuable. What feels restorative will be different for everyone, and it does not have to look like traditional ideas of “self-care”. Eating regularly and having a balanced diet can help you maintain your energy during what can be a very demanding period. Drinking to thirst is generally sufficient; you do not need to force yourself to drink large quantities of fluid in the hope that it will increase your milk production. Keeping a drink nearby when you are breastfeeding or expressing can simply make it easier to respond to your thirst. If expressing is becoming overwhelming, affecting your sleep, taking up most of your day or leaving you feeling that you cannot continue, it is worth talking to someone about the feeding plan. There may be ways to change when or how often you express, whether you need to express as frequently, how expressed milk is offered to your baby, or how other people can take on some of the practical work around feeding. Your baby may be the reason you are expressing, but your needs matter too. Supporting your physical recovery, rest and mental wellbeing is an important part of supporting your feeding journey. Storing expressed breastmilk Storage recommendations can vary between organisations and countries because storage temperature makes a significant difference. If you are in the UK, use current UK guidance rather than automatically following storage times you may find on websites from other countries. The NHS currently advises that freshly expressed milk can be stored: in the back of a fridge at 4°C or below for up to 8 days; for up to 3 days if the fridge temperature is unknown or between 5°C and 10°C; in an ice compartment for up to 2 weeks; in a freezer at -18°C or below for up to 6 months. The Breastfeeding Network gives slightly more cautious guidance of up to 5 days at 4°C or below, while noting that research has supported up to 8 days when the temperature remains stable at 4°C or below (Breastfeeding Network, 2026; NHS, 2026c). This is a good example of why the temperature of the fridge matters more than simply saying “breastmilk lasts X days”. If your baby is premature or unwell, follow the storage and transport guidance provided by their neonatal or clinical team, as this may differ from guidance for healthy full-term babies. Always wash your hands before expressing and use clean, appropriately sterilised equipment and containers. Label stored milk with the date and time it was expressed and store it towards the back of the fridge rather than in the door, where the temperature is more variable. Expressing does not have to look one particular way There is no single expressing routine that you have to follow. Your circumstances may change considerably over the course of your breastfeeding journey, and the way you express may need to change with them. Someone whose baby is premature or temporarily unable to breastfeed may initially need to express frequently throughout the day and night. As their baby becomes stronger and more effective at breastfeeding, they may gradually reduce expressing. Someone returning to work may express during working hours but breastfeed directly when they are at home, while another family may combine breastfeeding and expressed milk in a completely different pattern. You may also find that your preferred method changes over time. You might start with hand expression, move to a double electric pump while establishing your milk production, and later use a single or wearable pump for occasional expression. There is nothing wrong with changing the approach as your needs change. The same applies to the amount of milk you express. Some people want enough for an occasional bottle, while others need to express most or all of their baby's feeds. Some may express for a short period while their baby develops more effective feeding skills and then stop altogether. Rather than comparing your routine with someone else's, it can be more helpful to consider what you are trying to achieve, whether your baby is getting what they need, and whether the plan is manageable for you. A feeding plan that works well for one family may be completely impractical for another. When might additional support help? There may be times when individualised breastfeeding or lactation support is useful, particularly if expressing is painful, your nipples are becoming damaged, you cannot find a comfortable pump setting or you are unsure about flange fit. Support can also be helpful if your baby is not gaining weight as expected, you are expressing frequently but milk production is not increasing, you are producing much more milk than your baby needs, or you are experiencing recurrent breast inflammation or blocked areas. It is also reasonable to seek support simply because expressing is taking over your day, leaving you exhausted or making the feeding plan difficult to sustain. Sometimes a review of the whole feeding picture can identify ways to make the routine more manageable without compromising your baby's needs. A feeding assessment can help identify whether the issue is related to milk production, milk removal, infant feeding skills, equipment, pump settings, comfort, or a combination of factors. Expressing is a skill, not a test Expressing can take a little practice, particularly if you are learning to hand express or using a pump for the first time. It is also quite normal for the amount you collect to vary from one session to another. The amount collected during a single pumping session does not tell the whole story about your milk production, and a pump does not necessarily remove milk in exactly the same way that your baby does. Your milk may also flow differently depending on the time of day, how recently your baby fed, whether you are comfortable and relaxed, and how your body responds to the pump. If milk is not flowing, increasing the suction is not necessarily going to solve the problem. Sometimes a change in flange position, pump settings, stimulation, comfort or simply taking a short break can make more difference. Equally, if you are expressing because your breasts are inflamed, expressing more milk is not automatically the answer. If your baby needs additional milk, the feeding plan needs to consider both the baby's intake and your milk production rather than focusing only on how much can be expressed. Most importantly, expressing should be considered as one of the tools available to you rather than another measure of whether you are “doing breastfeeding right”. The approach that works for you may change over time, and it is perfectly reasonable for your expressing routine to look different from someone else's. Expressing can be an incredibly useful part of infant feeding, whether it is needed for a short period or becomes a longer-term part of your feeding journey. It should support you and your baby rather than becoming another source of pressure or exhaustion. References Breastfeeding Network (2026) Expressing and storing breastmilk. Available from: https://www.breastfeedingnetwork.org.uk/breastfeeding-information/continuing-the-breastfeeding-journey/expressing-and-storing-breastmilk/ Breastfeeding Network (2026) Mastitis Information. Available from: https://www.breastfeedingnetwork.org.uk/breastfeeding-information/mastitis-breastfeeding/ National Health Service (NHS) (2026a) Expressing and storing breast milk. Available from: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/expressing-breast-milk/ National Health Service (NHS) (2026b) Expressing breast milk by hand. Available from: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/expressing-your-breast-milk/expressing-breast-milk-by-hand/ National Health Service (NHS) (2026c) Storing breast milk. Available from: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/expressing-breast-milk/ National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. London: NICE. Forster, D.A. et al. (2017) ‘Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (DAME): a multicentre, unblinded, randomised controlled trial’, The Lancet, 389(10093), pp. 2204–2213. Mitchell, K.B. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum’, Breastfeeding Medicine, 17(5), pp. 360–376.

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

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.