A baby who once took a bottle comfortably may suddenly turn away, cry when feeding begins, take only small amounts, or feed when drowsy but resist when fully alert. Bottle refusal can feel worrying and deeply personal, particularly when every feed becomes something to anticipate rather than enjoy. It is not a reflection of how well a caregiver is caring for their baby. Bottle refusal is a recognised feeding experience, but it is not necessarily a diagnosis in itself. Sometimes there is an obvious reason for the change; sometimes several small factors come together. Research specifically about bottle refusal is surprisingly limited. Two UK studies by Maxwell, Fleming and Porcellato explored the experiences of breastfed babies refusing bottles and found a complex picture involving individual babies, feeding experiences and wider circumstances (Maxwell et al., 2020; Maxwell, Fleming and Porcellato, 2023). What does bottle feeding refusal mean? Bottle refusal is generally used to describe a baby who initially or continuously refuses to accept milk from a bottle. The term has been used particularly in research involving breastfed babies, although families may use it more broadly when a baby who previously accepted a bottle begins refusing it (Maxwell et al., 2020). You might notice that your baby: refuses the bottle altogether takes only a small amount before stopping sucks a few times and then turns away cries when the bottle is offered pushes the teat away becomes distressed as soon as feeding begins feeds more readily when sleepy or just waking accepts the bottle from one caregiver but not another accepts a bottle in one environment but refuses it somewhere else. A refusal does not necessarily mean that your baby has developed an aversion in the clinical sense. It may be a temporary response to illness, discomfort, developmental change, a change in routine or the way the feed is being offered. The word "refusal" can also make the situation sound more straightforward than it really is. A baby may be communicating that something about the feeding experience is difficult rather than simply deciding that they do not want a bottle. Research into bottle refusal suggests that babies are individuals and that several physical, psychological, biological and social factors may contribute (Maxwell, Fleming and Porcellato, 2023). As with all infant feeding concerns, anatomy provides information; function provides context. When does bottle refusal need prompt medical review? A sudden reduction in feeding can sometimes be associated with illness or another medical problem, so it is important not to assume that every feeding refusal is behavioural. Seek prompt medical advice if your baby is taking substantially less milk than usual, has significantly fewer wet nappies, is unusually sleepy or difficult to rouse, is not maintaining expected growth, or you are concerned that they are becoming dehydrated or unwell. Urgent medical assessment is needed if your baby has breathing difficulty, turns blue, grey or unusually pale, becomes difficult to rouse, or has other significant changes in their normal level of consciousness. Seek urgent advice if there is green or yellow-green vomit, blood in vomit, blood in the stool, repeated forceful vomiting, or other significant symptoms. NICE identifies these as potential red flags requiring clinical assessment rather than assuming that symptoms are simply reflux (NICE, 2015). If your baby is under 3 months old and has a temperature of 38°C or higher, seek urgent medical advice. These signs do not mean that your baby has bottle aversion. They may indicate an illness or another condition that needs assessment. If there are no urgent concerns but bottle feeding has consistently become difficult, it is still reasonable to ask for support. Earlier assessment can help identify whether there is a health, feeding or practical issue contributing to the difficulty. Looking at the whole feeding picture A detailed feeding history is often more informative than looking at one difficult feed in isolation. It can be helpful to think about: When did the change begin? Was your baby previously taking the bottle comfortably? Does the difficulty happen with every feed or only at particular times? Is your baby more willing to feed when sleepy or just waking? Does the refusal happen with every caregiver? Does it happen with breast milk, formula or both? Has anything changed recently? Has your baby been unwell or congested? Has there been a change in bowel movements or constipation? Is your baby teething? Has there been a change in the bottle, teat or flow? Is your baby coughing, spluttering, gulping or losing milk during feeds? Are there concerns about weight gain or wet nappies? It can also be useful to think about what happened around the time the refusal began. Sometimes a baby has experienced an uncomfortable or frightening feed, such as coughing, choking, vomiting, significant reflux-like discomfort or difficulty coordinating the feed. It is not possible to know exactly what an individual baby remembers or associates with a previous experience, but a difficult feeding experience may be followed by increased resistance at subsequent feeds. Physical discomfort can also affect feeding. Nasal congestion, illness, constipation, teething discomfort, reflux symptoms or other health concerns can all change how a baby approaches a feed. NICE specifically advises against assuming that unexplained feeding difficulties such as refusing feeds, gagging or choking are caused by reflux when overt regurgitation is not present (NICE, 2015). Looking at the wider picture is therefore important. Feeding difficulties can involve interacting medical, nutritional, feeding-skill and psychosocial factors, which is why a broader assessment can be more useful than looking for one isolated explanation (Goday et al., 2019). Could oral function be contributing? Oral function can be relevant to bottle feeding, particularly where there are several signs occurring together. You might notice: difficulty maintaining a consistent seal frequent milk loss from the mouth clicking or noisy feeding difficulty coordinating sucking, swallowing and breathing repeated coughing or spluttering very prolonged feeds marked fatigue during feeds frequent stopping and starting difficulty managing the flow of milk. However, none of these signs identifies a single cause. Teat shape and flow, positioning, feeding pace, nasal congestion, illness, developmental maturity, respiratory factors and individual feeding coordination can all influence bottle feeding. A visible lingual frenulum or tongue-tie does not, by itself, explain bottle refusal. Some babies with a tongue-tie feed effectively, while bottle feeding difficulties can occur for many reasons unrelated to tongue-tie. If you are concerned about oral function, it is more useful to consider what is happening during the feed than to make assumptions from the appearance of the mouth alone. You may find A Guide to Understanding Your Baby's Oral Function helpful when thinking about the wider feeding picture. Things you can try If your baby is otherwise well and there are no concerns about hydration, growth or feeding safety, there are several gentle things you can experiment with. The aim is not to find a way to make your baby take the bottle despite their cues. Instead, you are looking for circumstances in which feeding feels easier for your baby. Try changing the position Some babies feed more comfortably in one position than another. You could try a slightly different angle or a more upright, well-supported position while keeping your baby's face visible and airway clear. Position can affect how the teat sits in the mouth and how quickly milk reaches your baby. Responsive bottle feeding guidance recommends a semi-upright position and keeping the bottle relatively horizontal so that milk does not simply flow into the mouth continuously (NHS, n.d.). For more information about responsive and paced bottle feeding, see Paced Bottle Feeding. Think about the feeding environment Some babies become very distracted when they are more alert. Others feed better when there is some gentle movement, familiar conversation or another familiar sensory distraction. You could try: a quieter room a darker or less visually stimulating environment gentle background noise talking softly to your baby feeding somewhere familiar changing the amount of visual stimulation around your baby. There is no single environment that works for every baby. Notice whether a particular environment helps your baby settle or appears to overwhelm them. Distraction should not be used to override clear feeding cues or to encourage a baby to continue when they are trying to stop. Try a different feeding caregiver Some babies who resist the bottle from one caregiver will accept it from somebody else. This does not mean that your baby does not want to feed with their usual caregiver. A familiar caregiver may be associated with breastfeeding, previous feeding attempts or the expectation of a particular type of feed. Another familiar caregiver may be able to offer the bottle without the same expectations surrounding the feed. The aim should still be a calm, responsive experience rather than repeatedly testing whether the baby will accept the bottle. Consider whether the teat feels different The sensory experience of the teat may matter to an individual baby. Teats vary in: shape size softness texture flexibility material flow rate. Some families find that their baby responds differently to a change in teat material, such as moving between silicone and latex, although there is no evidence that one material is generally better for babies. If you are experimenting with a different teat, it can be useful to change one thing at a time so that you can tell what, if anything, appears to make a difference. Think about sucking before the feed Some babies seem to settle through sucking before they are ready to take milk. If your baby already uses a dummy, you could try allowing some non-feeding sucking before offering the bottle. Some babies may also settle by sucking on a clean finger for a short time. The aim is not to trick your baby into taking the bottle. If your baby is clearly refusing or becoming increasingly distressed, stop and try again later. Try gentle movement Some babies settle more readily with gentle movement. If your baby is securely held in your arms and positioned safely for feeding, you might find that gentle walking or rocking helps them become calmer. If you are walking while offering the bottle, keep your baby securely supported and maintain a safe feeding position. Do not feed while your baby is in a sling or carrier. Consider whether wind is contributing Trapped air may make some babies uncomfortable during or after feeds. You do not need to make every baby burp after every feed. Some babies need very little winding, while others appear more comfortable after releasing trapped air. If your baby becomes unsettled, pulls away, squirms or repeatedly stops and starts, you could pause the feed and give them an opportunity to wind before offering more milk. For more ideas, see How to Wind a Baby After a Feed. Think about pain and discomfort Teething, illness, a sore mouth, nasal congestion, constipation, reflux symptoms or another source of discomfort can all change how a baby approaches feeding. Look at what is happening outside the feed as well as during it. You might notice: increased chewing or drooling changes in bowel movements constipation nasal congestion unsettled behaviour when lying down signs of illness changes in wet nappies increased regurgitation or vomiting. If discomfort appears to be contributing to the feeding difficulty, addressing the underlying problem may be more helpful than continually changing the bottle. For more information about reflux and feeding, see Infant Reflux: Feeding, Self-Help and When to Seek Support. Try when your baby is sleepy Some babies who resist a bottle when fully alert will accept it when drowsy, just waking or calm. You may hear this described as dream feeding. If your baby feeds more comfortably when sleepy, that can provide useful information about what is happening when they are fully alert. It may suggest that your baby's state or the feeding environment is influencing the difficulty. However, sleepiness should not be used to override clear refusal. Your baby should still be able to pause or stop feeding according to their cues. Offer smaller amounts more frequently Some babies find a larger volume overwhelming, particularly if they are already unsettled around feeds. If your baby is otherwise well, offering smaller amounts more frequently may sometimes feel more manageable. Responsive feeding means allowing your baby to guide the feed rather than expecting them to finish a predetermined volume. Babies commonly feed little and often and do not necessarily finish every bottle (NHS, n.d.). If your baby has been given a medically advised minimum intake or feeding schedule, speak to the healthcare professional responsible for their care before making substantial changes. Look for patterns If bottle refusal is happening repeatedly, a short feeding diary can help you see patterns that are difficult to notice from individual feeds. You could record: time of feed whether your baby was fully awake, sleepy or just waking caregiver offering the feed location bottle and teat used position approximate amount offered and taken coughing, gulping or milk loss winding vomiting or regurgitation bowel movements wet nappies signs of teething or illness anything different about that feed. The purpose is not to monitor every millilitre anxiously. It is to look for patterns that may help you understand what is making some feeds easier or harder. Could something have happened during a previous feed? Sometimes bottle refusal begins after a particularly difficult feeding experience. This could include: a significant coughing or choking episode vomiting during a feed painful reflux-like symptoms milk flowing much faster than your baby could comfortably manage difficulty coordinating sucking, swallowing and breathing another experience that appeared frightening or uncomfortable. It is difficult to know exactly what an infant remembers or associates with a previous feed. However, if refusal began after a particularly difficult experience, repeatedly encouraging the baby to take the same bottle may increase distress. Instead, try to make subsequent feeding experiences calm and predictable. Offer the bottle without pressure, allow your baby to pause and stop when they communicate that they have had enough. Supporting a baby who is distressed by the bottle Repeated pressure can make feeding increasingly tense. Re-offering the bottle immediately after a clear refusal, repeatedly trying to persuade a baby to continue, or prolonging a distressed feed can turn feeding into a struggle for both of you. Responsive bottle feeding means watching your baby's cues rather than focusing only on completing a particular volume. Your baby may communicate that they need a pause by: slowing or stopping sucking turning their head away pushing the teat away spilling milk splaying their fingers becoming tense becoming distracted showing other signs that they need a break. These behaviours are communication rather than something that needs to be overcome. You can find more detail in Paced Bottle Feeding. If you are trying different approaches, consider changing one variable at a time. Changing the bottle, teat, flow rate, caregiver, room, position and routine all at once can make it almost impossible to know what has helped. If bottle feeding remains difficult, an alternative feeding method may sometimes provide another way of meeting your baby's nutritional needs while the difficulty is being explored. Read Alternative Feeding Methods for more information. Alternative feeding methods are not a failure of bottle feeding. They are simply different ways of providing milk when a particular method is not currently working well for an individual baby. A role for skilled, joined-up support Bottle refusal can involve more than the bottle itself. A skilled feeding assessment may consider: your baby's medical history growth and hydration feeding history feeding cues positioning bottle and teat milk flow sucking, swallowing and breathing oral function discomfort the feeding environment what happens before, during and after feeds and the experience of the caregiver and baby together. A feeding difficulty may need medical review, feeding support, changes to the way milk is offered, monitoring over time or a combination of approaches. The purpose of assessment is not necessarily to identify something that needs treating. Sometimes careful assessment provides reassurance that a baby is well and that a period of refusal can be supported conservatively. If expressing is part of your feeding plan, you may also find Expressing Breast Milk useful. Moving forward with compassion A difficult feeding period can make caregivers feel that they need to solve everything immediately. A useful starting point is to consider: 1. Is my baby well and hydrated? 2. Is there anything that could be causing pain or discomfort? 3. Is there a pattern to when refusal happens? 4. Can I reduce pressure around the feed? 5. Is there one small change I can try rather than changing everything at once? 6. Do I need help assessing what is happening during the feed? Sometimes a different position, quieter environment, another caregiver, a winding break, a different sensory experience or smaller, more frequent feeds can make feeding easier. Sometimes there is an underlying medical or feeding difficulty that needs professional assessment. And sometimes several small factors are contributing at the same time. Bottle refusal does not mean that you have done something wrong, and it does not necessarily mean that your baby will never take a bottle. Every feeding journey deserves careful attention to the individual baby, the feeding relationship and the circumstances surrounding the difficulty. References Goday, P.S., Huh, S.Y., Silverman, A., Lukens, C.T., Dodrill, P., Cohen, S.S., Delaney, A.L., Feuling, M.B., Noel, R.J., Gisel, E., Kenzer, A., Kessler, D.B., Kraus de Camargo, O., Browne, J. and Phalen, J.A. (2019) ‘Pediatric feeding disorder: Consensus definition and conceptual framework’, Journal of Pediatric Gastroenterology and Nutrition, 68(1), pp. 124–129. doi:10.1097/MPG.0000000000002188. Kerzner, B., Milano, K., MacLean, W.C., Berall, G., Stuart, S. and Chatoor, I. (2015) ‘A practical approach to classifying and managing feeding difficulties’, Pediatrics, 135(2), pp. 344–353. Maxwell, C., Fleming, K.M., Fleming, V. and Porcellato, L. (2020) ‘UK mothers’ experiences of bottle refusal by their breastfed baby’, Maternal & Child Nutrition, 16(4), e13047. doi:10.1111/mcn.13047. Maxwell, C., Fleming, V. and Porcellato, L. (2023) ‘Why have a bottle when you can have draught? Exploring bottle refusal by breastfed babies’, Maternal & Child Nutrition, 19(2), e13481. doi:10.1111/mcn.13481. National Health Service (NHS) (n.d.) ‘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/ (Accessed: 17 September 2026). National Health Service (NHS) (n.d.) ‘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/ (Accessed: 17 September 2026). National Institute for Health and Care Excellence (NICE) (2015, updated 2019) Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NICE guideline NG1. London: NICE. Available at: https://www.nice.org.uk/guidance/ng1 (Accessed: 17 September 2026).

A baby who turns towards the breast or bottle, opens their mouth, licks their lips, stirs, or brings a hand towards their face is communicating before they cry. Recognising feeding cues can help families respond at a point when feeding may feel calmer, rather than trying to settle a very distressed baby first. It is not about getting every cue right. Babies do not use a universal language in which one behaviour always means one thing. It is about becoming familiar with your individual baby's patterns, needs and ways of communicating. Responsive feeding is relevant whether a baby feeds at the breast, chest/body feeds, takes expressed milk, feeds by bottle, or has a combination of feeding methods. It supports a feeding relationship in which the adult notices, responds and adapts, while also paying attention to their own wellbeing and practical circumstances. What are feeding cues? Feeding cues are behaviours that may indicate that a baby is becoming hungry, is ready to feed, is interested in sucking, or has had enough. They are part of normal infant communication, but they are not a precise language. A baby may show several cues together, and the pattern can become more obvious as hunger increases. However, an individual behaviour should not automatically be interpreted as hunger. For example, a baby putting their hands in their mouth may be hungry, but they may also be tired, seeking comfort, exploring their hands or, as they get older, experiencing teething discomfort. A baby turning their head may be rooting for the breast or bottle, but turning away during a feed can also be a way of taking a break or reducing stimulation. Context matters. Consider when the last feed was, whether your baby is waking from sleep, their usual feeding rhythm, their age and developmental stage, how they seem physically and emotionally, and what happens when you offer comfort or a feed. A responsive approach is therefore not a rule that every cue must lead to milk. It is attentive observation followed by a thoughtful response. Research on responsive feeding suggests that it may support healthy feeding interactions and self-regulation. However, much of the evidence is observational, and feeding behaviour is influenced by many factors, including infant temperament, family routines, milk availability, health and social support. It is therefore best understood as a helpful principle rather than a guarantee of any particular outcome (DiSantis et al., 2011; Hurley, Cross and Hughes, 2011). What do feeding cues look like? There is no single list that every baby will follow. Some babies show several cues, while others have a much shorter or less obvious sequence. Common feeding cues include: stirring or wriggling becoming more alert or active waking from sleep moving the eyes beneath closed eyelids licking or smacking the lips making sucking movements poking the tongue out opening and closing the mouth bringing hands towards the mouth or face sucking or chewing fingers, fists or hands turning the head from side to side rooting, with the mouth opening as the head turns towards the breast or bottle nuzzling or bobbing towards the breast or bottle becoming increasingly restless making small sounds or becoming more vocal. NCT and NHS guidance both describe behaviours such as hand-to-mouth movements, rooting, mouth movements, restlessness and sucking on fingers as common feeding or hunger cues (NCT, 2025; NHS, 2024). These behaviours may occur before crying and can be useful opportunities to offer a feed. Early feeding cues Early cues can be particularly subtle in newborn babies. A sleepy newborn may begin by stirring, stretching, moving their eyes, making small mouth movements or becoming slightly more alert. They may lick or smack their lips, poke their tongue out, open their mouth or bring their hands towards their face. Some babies will begin sucking their fingers or fists. Others may turn their head from side to side or root when their cheek or mouth comes into contact with a person. These early behaviours can be easy to overlook, particularly during the first few weeks when families are still learning their baby's individual patterns. Skin-to-skin contact, where appropriate and safe, can make some of these behaviours easier to notice and may support feeding responsiveness and breastfeeding initiation (Moore et al., 2016). As hunger increases If a baby is becoming hungrier, their movements may become more obvious. They may: wriggle more strongly become increasingly restless repeatedly turn their head and root open their mouth widely suck more vigorously on their hands or fingers nuzzle into the person holding them bob their head towards the breast or bottle make more persistent sucking or feeding sounds become increasingly focused on finding something to suck. At this point, a baby may still be relatively calm and able to coordinate feeding comfortably. The aim is not to rush. Instead, it is to notice the communication and offer an opportunity to feed. Positioning, comfort, milk flow, the feeding environment and previous feeding experiences can all affect how a feed unfolds. Crying is a late cue Crying is a powerful way for a baby to communicate, but it is generally a later sign of hunger. A very distressed baby may also become red, agitated, arch or stiffen their body, move their head from side to side, or become difficult to settle. Once a baby is crying intensely, it may be harder for them to organise themselves for feeding. They may need some help to calm before they can comfortably attach to the breast or accept a bottle (NCT, 2025; NHS, 2024). Holding your baby close, reducing stimulation and using the comfort that usually works for your family may help them settle before you offer the feed again. This is not a sign of parental failure, nor does it mean that a family has deliberately missed their baby's cues. Babies can move from subtle cues to distress very quickly, and some babies give very little warning. One cue can mean more than one thing Perhaps the most important thing to understand about feeding cues is that one behaviour does not always have one meaning. A baby chewing their hands may be hungry, but they may also be tired, seeking comfort, exploring their hands or, later in infancy, experiencing teething discomfort. Licking their lips may occur around feeding, but babies also make many mouth movements during normal development. Turning towards the breast or bottle may indicate rooting, but babies also turn towards people, voices and other interesting things. Sucking can be soothing as well as nutritive. This is why it is better to look for a pattern of cues rather than deciding that one behaviour automatically means "my baby is hungry". For example, a baby who has recently had a good feed and is now chewing their hands may simply be exploring or settling. A baby who has not fed for some time and is becoming increasingly alert, licking their lips, opening their mouth and rooting gives a much stronger overall picture that they may be ready to feed. Your baby's behaviour also needs to be considered alongside their wider wellbeing, including feeding frequency, milk transfer, wet nappies, growth and how they generally appear. Feeding cues change as babies grow Your baby's feeding communication will not necessarily look the same throughout the first year. Newborn babies often communicate through relatively small changes in movement, alertness, mouth movements, sucking and rooting. As babies become more alert and physically capable, their communication becomes more varied. They may become more purposeful about reaching, bringing objects or hands to their mouth, turning towards a feeding person, opening their mouth or seeking the breast or bottle. This does not mean that every new behaviour should be interpreted as a feeding cue. For example, around the time babies begin approaching complementary feeding, families may notice more hand chewing, waking during the night or wanting additional milk feeds. These behaviours can sometimes be interpreted as signs that a baby is ready for solid foods. They are not, on their own, signs of readiness for complementary foods. NHS guidance identifies three developmental signs that should be present together from around six months: your baby can stay in a sitting position and hold their head steady your baby can coordinate their eyes, hands and mouth so they can look at food, pick it up and put it in their mouth your baby can swallow food rather than automatically pushing it back out. Chewing fists, waking more frequently during the night and wanting additional milk feeds can all be normal behaviours and are not, by themselves, signs that a baby is ready for solids (NHS, 2026). Newborns feed frequently Newborn babies normally feed frequently. In the early weeks, it is common for a baby to feed many times across a 24-hour period, and there may be periods when they want to feed repeatedly over several hours. This is often called cluster feeding. During cluster feeding, a baby may feed, have a short pause, and then show feeding cues again. They may want to return to the breast or bottle several times within a relatively short period. This can be particularly noticeable at certain times of day. Babies may also temporarily want to feed more frequently as they move through different developmental stages. Their needs and feeding patterns change as they grow, and periods of increased feeding can be a normal part of infancy. Cluster feeding and increased feeding frequency do not automatically mean that a baby is not getting enough milk. For a breastfed baby, frequent feeding can be part of the normal process of establishing and maintaining milk production. For a bottle-fed baby, frequent feeding can also occur, although responsive bottle feeding remains important so that the baby's cues for pauses and fullness are followed. It can be difficult to distinguish normal frequent feeding from a feeding problem when you are tired and unsure whether your baby is getting enough. Rather than judging feeding by frequency alone, look at the wider picture. Consider whether your baby is feeding actively, whether they appear satisfied after at least some feeds, their wet and dirty nappies, weight gain and general wellbeing. A baby who wants to feed frequently but is otherwise well, has appropriate output and is growing as expected may simply be a baby who feeds frequently. Conversely, a baby who is feeding almost continuously, rarely seems satisfied, is repeatedly falling asleep before feeding effectively, is difficult to wake for feeds, has reduced urine output, is not gaining weight as expected or is becoming increasingly unsettled may need an individual feeding assessment. Frequent feeding is not, by itself, evidence that something is wrong — but neither should persistent feeding difficulties be dismissed simply because newborns feed frequently. The pattern matters. Cues during a feed matter too Responsive feeding includes noticing what happens after feeding begins. A baby who is actively feeding may show rhythmic sucking and swallowing, with periods of pausing that vary according to age, milk flow and individual feeding style. There is wide normal variation. A baby may indicate that they need a pause by: turning away slowing markedly becoming tense spreading their fingers stopping sucking losing their organised pattern of feeding. A baby who reorients, opens their mouth or seeks the breast or teat again may be indicating continued interest. For bottle-fed babies, following these cues can help avoid encouraging a baby to take more milk simply because milk remains in the bottle. Responsive bottle feeding includes allowing pauses and stopping when the baby shows that they have had enough rather than encouraging them to finish the bottle (NCT, 2025; NHS, 2024). How might a baby show they have had enough? Babies may communicate that they are finished in several different ways. They may: release the breast move away from the bottle or teat turn their head away stop sucking relax their hands and body become calm and settled fall asleep after a feed. Some babies feed from one breast and are satisfied, while others want both. Some bottle-fed babies will leave milk in the bottle. A bottle does not need to be emptied for a feed to be successful. Equally, falling asleep quickly does not automatically mean that a baby has finished feeding. If a baby consistently falls asleep very quickly, remains difficult to wake for feeds, feeds for unusually long periods, or there are concerns about milk transfer, wet nappies, weight gain or general wellbeing, the wider picture needs to be considered. Feeding cues are only one part of the picture Cue recognition can be particularly reassuring when feeding is going smoothly. It becomes more complex when a baby is feeding very frequently, appears unsettled, coughs or splutters during feeds, repeatedly comes off the breast or bottle, takes unusually long feeds, or seems unable to remain comfortably engaged. These experiences can have many possible contributors. They may relate to normal developmental changes, milk flow, positioning, breast or chest comfort, bottle-feeding dynamics, illness, reflux-like symptoms, sensory needs, prematurity, birth history or oral function. Tongue anatomy may provide useful information in some assessments, but anatomy alone cannot explain a feeding experience. Function, milk transfer, feeding observation, infant growth and the family's experience provide essential context. For families concerned about tongue-tie, it is reasonable to seek skilled support without assuming that a particular diagnosis or treatment is needed. A comprehensive assessment should consider the whole feeding situation and discuss conservative support, onward referral or other options through collaborative decision-making. When feeding cues need prompt clinical attention Trust your instincts if your baby seems unwell or feeding has changed suddenly. Seek prompt advice from your midwife, health visitor, GP, maternity unit or local urgent care service if your baby: is difficult to wake for feeds persistently refuses feeds has noticeably fewer wet nappies than expected shows worsening jaundice vomits repeatedly is not feeding as usual or you are worried about weight gain or dehydration. Urgent emergency help is needed if a baby has breathing difficulty, is blue, grey or very pale, is floppy or unresponsive, or you believe they are seriously unwell. Feeding concerns deserve to be heard, especially when they are accompanied by changes in behaviour, output or growth. A gentle way to build confidence Rather than watching the clock alone, spend a few days noticing what happens before your baby usually feeds. You may begin to see a pattern: stirring → waking → mouth movements → lip licking → hands towards the mouth → rooting → opening the mouth → active searching → crying Another baby may have a completely different sequence, or may move from subtle cues to crying very quickly. There is no prize for identifying the first possible cue. The goal is not perfect cue-reading. It is learning your baby's individual way of communicating and responding as thoughtfully as possible. If you are unsure whether a behaviour means hunger, consider the whole picture rather than relying on the behaviour alone. Ask yourself: When did my baby last feed? Are they waking from sleep? What is their usual feeding pattern? Do they appear calm, alert, tired or overstimulated? Are there several feeding cues occurring together? What happens when I offer a feed? What happens when I offer comfort instead? Are they otherwise well and growing as expected? For healthcare professionals, cue-based conversations offer a useful opening for clinical reasoning. Asking what the family sees before, during and after feeds, whether the cues differ by time of day, and what the baby's growth, output and general wellbeing suggest can help put individual behaviours into context. This also respects the knowledge families develop about their own baby. Every feeding journey deserves support, compassion and reassurance. The goal is not to identify every cue perfectly. It is to develop a growing understanding between baby and caregiver, while recognising when skilled feeding support is needed. References DiSantis, K.I., Hodges, E.A., Johnson, S.L. and Fisher, J.O. (2011) ‘The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review’, International Journal of Obesity, 35(4), pp. 480–492. Hurley, K.M., Cross, M.B. and Hughes, S.O. (2011) ‘A systematic review of responsive feeding and child obesity in infancy’, American Journal of Preventive Medicine, 41(2), pp. 226–229. Moore, E.R., Bergman, N., Anderson, G.C. and Medley, N. (2016) ‘Early skin-to-skin contact for mothers and their healthy newborn infants’, Cochrane Database of Systematic Reviews, 11, CD003519. National Childbirth Trust (NCT) (2025) ‘Breastfeeding: cues, attachment and positions’. Available at: https://www.nct.org.uk/information/baby-toddler/feeding-your-baby-or-toddler/breastfeeding-cues-attachment-and-positions (Accessed: 13 September 2026). National Childbirth Trust (NCT) (2025) ‘How to bottle-feed’. Available at: https://www.nct.org.uk/information/baby-toddler/feeding-your-baby-or-toddler/how-bottle-feed (Accessed: 13 September 2026). National Health Service (NHS) (2024) ‘Feeding on demand – bottle feeding’. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/feeding-on-demand/ (Accessed: 13 September 2026). National Health Service (NHS) (2026) ‘How to start weaning’. Available at: https://www.nhs.uk/best-start-in-life/baby/weaning/how-to-start-weaning-your-baby/ (Accessed: 13 September 2026).

The first night after a tongue-tie division can feel like a big moment. You may have hoped that feeding would suddenly feel easier, but it is important to know that an immediate transformation is not what most families should expect. A tongue-tie division changes the physical restriction, but it does not instantly change a baby's feeding skills, muscle strength, coordination, milk supply, positioning or the many other things that influence feeding. Baby and feeding dyad are learning how to use the new movement together. For a broader explanation of what can happen after a tongue-tie release, see What to Expect After a Tongue-tie Release. This article looks specifically at those first few hours and the first night, when things can feel particularly unfamiliar. The first feed may not be dramatically different Some babies show an immediate change in feeding, but it is more normal and expected that feeding does not suddenly become easier straight away. The tongue has been released, but it is still a muscle that needs to develop strength, coordination and endurance with its new range of movement. Oakley (2024) describes how a baby may initially have a more mobile tongue but struggle to use that movement effectively, while Smyth (2016) describes the early period as potentially being “two steps forward, one step back”. This means that a difficult feed on the first night is not a prediction of how feeding will develop. It is one feed within a process that is still developing. You may have a feed that seems noticeably better, followed by one that feels much harder. You may see periods where your baby appears to be doing something completely differently, followed by a return to familiar feeding behaviours. This can be unsettling when you have been hoping for an immediate improvement, but it does not necessarily mean that the procedure has not helped. Your baby's tongue may tire A tongue that has previously been working within a restricted range may not immediately have the strength or coordination to make the most of its new movement. Oakley (2024) describes babies sometimes having a more mobile tongue following division but initially finding it difficult to use effectively because of reduced strength or tone. Smyth (2016) also describes the tongue as a muscle that can become tired as the baby adjusts to using it differently. This can mean that a feed may start well and then become less coordinated as your baby becomes tired. You may notice more breaks, changes in sucking, difficulty maintaining a seal or a baby who simply seems to have had enough. Regular feeding provides opportunities for your baby to use this new movement, but there is no need to turn every feed into a practice session. Feeding remains feeding, and your baby still needs to be allowed to take breaks and settle when needed. You may notice more wind Another thing some families notice after a tongue-tie division is increased wind or a baby who seems more uncomfortable with trapped air. There are several possible reasons for this. A baby who is learning to coordinate a newly released tongue may temporarily have a less consistent seal or less coordinated sucking pattern, which can result in more air being swallowed. This is a plausible part of the adjustment period, although there is limited research establishing exactly how frequently this occurs or the precise mechanism in individual babies. If your baby seems windy, take your usual approach to winding and give them time to settle. There is no need to assume that increased wind means something has gone wrong. Keep offering feeds regularly Regular feeding gives your baby opportunities to use the new tongue movement while continuing to meet their nutritional needs. If breastfeeding, continue to offer the breast responsively and allow your baby to feed according to their usual pattern. A baby may have some shorter or less efficient feeds while they are adjusting, so keeping an eye on the overall picture is more useful than judging everything from one feed. For bottle-fed babies, smaller amounts taken more frequently may sometimes feel easier than trying to encourage a baby to take their usual volume in one go. Follow your baby's usual feeding pattern as far as possible and avoid pressuring them to finish a bottle. The aim is not to achieve a perfect feed on the first night. It is to give your baby opportunities to feed, rest, settle and try again. If a feed is difficult, take the pressure off If feeding is becoming stressful for both of you, it is perfectly reasonable to pause and help your baby settle before trying again. Skin-to-skin contact can be particularly useful. It can help babies to regulate their temperature, breathing and heart rate and can support feeding behaviours and milk production (NHS, 2025). You do not have to wait until your baby is feeding perfectly to use skin-to-skin. Holding your baby, rocking gently, using a familiar voice or humming, and allowing some quiet time can also help. Some babies respond well to sucking when they are unsettled, whether that is at the breast or through another form of non-nutritive sucking that is already familiar to them. There is no single soothing technique that works for every baby. What matters is finding something familiar that helps your baby feel safe and settled. Keep the environment familiar The first night is probably not the time to introduce lots of new stimulation. If your baby normally settles in a particular way, keep as much of that routine as possible. You might dim the lights, turn off the television, reduce background noise and give your baby a quieter environment in which to feed and settle. You know your baby better than anyone. If your baby normally enjoys being held quietly in a darkened room, that may be more helpful than introducing something completely new. The same applies to bathing. If your baby normally finds a warm bath relaxing, it may be a lovely way to settle them. If your baby dislikes baths, however, this is not the night to introduce one as a calming strategy. Choose what your baby already knows and generally responds well to. Sucking can be comforting Sucking is naturally regulating for many babies. If your baby is already comfortable with non-nutritive sucking, this may be another way of helping them settle between feeds. For some babies, being held close and allowed to suck a clean finger may be calming. Others may prefer the breast, a bottle or another familiar method of soothing. The important thing is not to introduce something simply because you have been told that you should. Use what is familiar and appropriate for your baby. Keep an eye on the bigger picture It is easy to become very focused on the tongue after the procedure, particularly when you have been looking at it closely for weeks. Try to step back and look at your baby as a whole. Are they continuing to feed? Are they having their usual wet nappies? Are they waking for feeds and settling between them? Does their overall behaviour seem reasonably like your baby? One difficult feed does not tell you what is happening with your baby's overall intake. Likewise, one particularly good feed does not necessarily mean that everything has suddenly changed. If you have been advised to monitor your baby's weight, continue to do this as recommended. Nappy output and the overall pattern of feeding can also help you to understand how things are progressing. What about pain relief? Most babies having a tongue-tie division are very young, so there may not be an over-the-counter medicine that is appropriate for them. Comfort measures should therefore be the first consideration. Skin-to-skin contact, feeding, sucking, being held, familiar voices and a calm, familiar environment can all help a baby to settle. If your baby is old enough to have an appropriate infant paracetamol preparation, follow the instructions on the product carefully and make sure the preparation is suitable for your baby's age and circumstances. Most infant preparations are labelled for babies aged 3 months and over. There are some specific circumstances in which paracetamol may be given to a baby aged 2–3 months, but this is not a general recommendation for babies of this age. NHS guidance specifies that the baby must weigh more than 4 kg and have been born after 37 weeks, with limits on the number of doses that can be given. If your baby is under 3 months, check with a pharmacist, GP or other appropriate healthcare professional rather than assuming that an over-the-counter preparation is suitable (NHS, 2025). It is also important not to assume that crying means that the wound itself is causing significant pain. Babies can cry because they are hungry, tired, windy, overstimulated, frustrated or simply finding the whole experience unfamiliar. The lingual frenulum does have sensory innervation, so it would be too strong to say that the procedure or healing wound cannot cause discomfort. However, there is limited evidence about how much pain individual babies experience following frenotomy, and the available research has not established a reliable way of predicting this for a particular infant (O'Shea et al., 2017; Mills et al., 2019). Try not to keep checking the wound It is understandable to want to look at the area after the procedure, particularly if you are worried about how it is healing. However, repeatedly checking the wound can make an already stressful evening feel much more difficult. The appearance of the healing area can also change over the following days, so what you see immediately after the procedure is not necessarily what it will look like as it heals. For more information about healing and aftercare, see Beyond the Tongue-tie Release: Why Aftercare Matters and Wound Healing in Infants After a Tongue-tie Release. Follow the aftercare information provided by your chosen practitioner rather than repeatedly interfering with the healing area. Current professional guidance does not support routinely disrupting the healing wound in an attempt to prevent reattachment. Your chosen practitioner is there to support you If you are worried about your baby's feeding, wound, bleeding, intake or general wellbeing after the procedure, contact the practitioner who performed the tongue-tie division. They have assessed your baby, performed the procedure and know the individual circumstances, so they are best placed to advise you about what you are seeing and whether your baby needs further assessment. It is entirely reasonable to contact them if you are unsure. You do not need to work out for yourself whether something is within the expected range. Look after yourself too The first night can be tiring for everyone, particularly if feeding is taking longer than usual or your baby is unsettled. If there are two caregivers available, take turns where you can. One person may be able to settle or hold the baby while the other has a shower, eats something or simply has some quiet time. If you are on your own, accept help from someone you trust if it is available. Keep a drink beside you and make food as easy as possible. This is not the night to worry about having a tidy house or catching up on everything that has been left undone. The procedure may have been a big event for you too. You have probably spent time thinking about the decision, preparing for the appointment and hoping that things will improve. It is okay if the first night feels emotionally bigger than you expected. A difficult feed does not mean you are going backwards It can be very easy to interpret a difficult feed as evidence that something has gone wrong, particularly if you had seen an improvement immediately after the procedure. Try to remember that feeding is a process rather than a single event. Smyth (2016) describes this early period as “two steps forward, one step back”, with good and difficult feeds potentially occurring alongside one another before the new pattern becomes more predictable. Oakley (2024) similarly describes the adjustment period following division and the time it can take for a baby to develop more effective use of the newly available movement. A difficult feed tonight is not a prediction of how feeding will develop. It is one feed within a learning process for both your baby and the feeding dyad. Tomorrow is another feeding day, with another opportunity to see how your baby is adapting. When to ask for further advice Contact your chosen practitioner or another appropriate healthcare professional if you are concerned about persistent bleeding, your baby is consistently struggling to feed, there are noticeably fewer wet nappies than expected, your baby develops a fever, or your baby seems unusually sleepy, unwell or different from their normal behaviour. You do not need to wait until you are certain that something is wrong. If something does not feel right to you, it is appropriate to ask for advice. The first night does not need to be perfect. Your baby may be unsettled, feeding may feel unfamiliar and you may wonder whether anything has changed at all. That does not necessarily mean that the procedure has not been helpful. For many babies, learning to use a newly released tongue takes time. There may be better feeds, more difficult feeds, tiredness, wind and moments when you wonder whether you are making progress. These early experiences are part of the adjustment for some feeding dyads. Be kind to yourself, keep your baby's overall wellbeing and intake in view, use the familiar things that help your baby settle, and remember that one difficult night does not define what happens next. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. Available at: https://doi.org/10.1089/bfm.2021.29188.abm Mills, N., Keough, N., Geddes, D.T., Pransky, S.M. and Mirjalili, S.A. (2019) ‘Defining the anatomy of the neonatal lingual frenulum’, Clinical Anatomy, 32(7), pp. 824–835. Available at: https://doi.org/10.1002/ca.23410 Mills, N., Pransky, S.M., Geddes, D.T. 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. Available at: https://doi.org/10.1002/ca.23343 NHS (2025) ‘Paracetamol for children’. Available at: https://www.nhs.uk/medicines/paracetamol-for-children/ NHS (2025) ‘Skin-to-skin contact with your newborn’. Available at: https://www.nhs.uk/best-start-in-life/baby/baby-basics/caring-for-your-baby/skin-to-skin-contact-with-your-newborn/ O'Shea, J.E., Foster, J.P., O'Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. Available at: https://doi.org/10.1002/14651858.CD011065.pub2 Oakley, S. (2024) Tongue-tie in Babies: A Guide for Parents. Available at: https://sarahoakleylactation.co.uk/wp-content/uploads/2024/03/Parents-Guide-to-Tongue-tie-2024-2.pdf Smyth, C. (2016) ‘What to Expect after Tongue Tie Release (2 steps forward, 1 step back)’, 10 June. Available at: https://www.carolsmyth.co.uk/perinatal-infant/breastfeeding-resources/posts/2016/june/what-to-expect-after-tongue-tie-release/

Feeding a baby does not always follow one predictable route. Some babies breastfeed directly, some take milk from a bottle, and others may need a different approach for a period of time. Families may also choose to use more than one method as circumstances change. Alternative feeding methods can provide a way to give expressed breast milk, donor milk or infant formula when direct breastfeeding or bottle feeding is not currently possible, is not working well, or simply does not fit the circumstances. They may be used temporarily while a baby develops feeding skills, while milk supply is being established or maintained, during periods of illness or separation, or as part of a longer-term feeding plan. There is no single method that is right for every baby. The most appropriate option depends on your baby's age, gestation, health, alertness, feeding skills and ability to coordinate sucking, swallowing and breathing, alongside the type and amount of milk required and what is practical for the family. Alternative feeding should not be viewed as a failure of breastfeeding, bottle feeding or combination feeding. These are simply different ways of getting milk to a baby, and a feeding plan can change as the baby and family circumstances change. Anatomy provides information. Function provides context. How your baby feeds, their growth and hydration, milk transfer, milk supply, medical history and feeding observations all contribute to deciding what support may be appropriate. When might an alternative feeding method be considered? There are many reasons why a baby may temporarily or longer-term need milk to be provided in a different way. This may include: a baby who is learning to breastfeed or bottle feed difficulties with milk transfer at the breast a baby who is not currently able to take enough milk directly from the breast temporary separation between baby and breastfeeding parent establishing or maintaining milk supply while feeding skills develop recovery from illness or a procedure prematurity or developmental immaturity a baby who is transitioning between feeding methods combination feeding a family choosing a different way of providing milk a baby who needs additional milk alongside breastfeeding. Sometimes the alternative method is only needed for a short period. In other situations, it may form part of a longer-term feeding plan. The important question is not simply which method is available, but which method is appropriate and safe for this individual baby. Is an alternative feeding method suitable for your baby? Choosing an alternative feeding method is not simply about choosing a piece of equipment. Your baby's ability to manage the method safely needs to be considered first. A trained healthcare professional should assess your baby's overall health and feeding ability before recommending an alternative method. Where relevant, this may include an oral assessment looking at the baby's lips, tongue, jaw, palate, oral movement and ability to coordinate sucking, swallowing and breathing. An oral assessment should form part of a wider feeding assessment rather than being used in isolation. Your baby's age, gestation, alertness, medical history, growth, hydration, feeding experience and the amount and type of milk required are also important. The presence of a visible frenulum does not automatically mean that an alternative feeding method is unsuitable, and an alternative method should not be selected simply because a baby has a tongue-tie. What matters is how the individual baby is functioning and whether they can safely manage the proposed method. A baby who is clinically well and feeding safely may be able to use an alternative feeding method at home when it has been specifically recommended and demonstrated by an appropriately trained healthcare professional. Babies with underlying medical conditions may need additional assessment, monitoring or intervention. For example, babies with cardiac conditions, respiratory problems, neurological conditions, significant prematurity or other complex health needs may have different feeding requirements and should have an individual feeding plan developed with the relevant clinical team. Home use should therefore never be assumed simply because a method is listed as an option. The suitability of the method needs to be established for your baby first. Safety comes before the method The methods described in this article are intended to show that families have different options when an alternative way of providing milk is needed. This is not a teaching guide or a substitute for individual assessment and practical instruction. Before any alternative feeding method is attempted, your baby should be assessed by an appropriately trained healthcare professional, who can determine whether the method is suitable and demonstrate it to you face to face. You should be shown how to position your baby, how to offer the milk, how to recognise when your baby needs a pause and what signs would mean that the method is not being managed safely. The amount of milk and the speed at which it is offered also matter. A method that allows milk to enter the mouth faster than a baby can comfortably manage may increase the risk of coughing, choking or aspiration. Aspiration means milk entering the airway rather than travelling safely down the oesophagus into the stomach. Significant aspiration can cause serious illness, including aspiration pneumonia. This does not mean that alternative feeding methods are inherently unsafe. It means that the method, volume and pace need to be appropriate for the individual baby. There is no universal volume or feeding speed that is appropriate for every baby. Factors including age, gestation, weight, health, alertness, feeding skills and your baby's ability to coordinate sucking, swallowing and breathing all need to be considered. Whatever method is used, your baby should remain visible to you throughout the feed and be appropriately positioned for that method. Milk should never be poured or pushed into your baby's mouth. Your baby's cues should be observed throughout the feed, with pauses allowed rather than focusing only on completing a particular volume. If a method has been recommended for your baby, it must be demonstrated to you face to face by an appropriately trained healthcare professional before you attempt it at home. If your baby develops difficulty breathing, turns blue, grey or unusually pale, becomes unresponsive or has a significant change in their normal level of consciousness during or after a feed, call 999. The information in this article is provided for general educational purposes and to demonstrate the range of alternative feeding options available. It cannot assess your individual baby, determine which method is appropriate, or provide the practical instruction needed to use a method safely. D-Restricted Ltd® cannot accept responsibility for the use of an alternative feeding method without appropriate individual assessment, face-to-face instruction and clinical oversight. Breastfeeding at the breast For some families, the alternative to bottle feeding may actually be breastfeeding at the breast. This might sound unusual in an article about alternative feeding methods, but breastfeeding can sometimes remove the need for another milk-delivery method altogether. Some babies who are struggling with bottles may breastfeed effectively, while others may be able to breastfeed for some feeds but need additional milk at other times. Breastfeeding can also form part of a combination-feeding plan, with bottles or other methods used for some feeds and breastfeeding for others. The important consideration is whether your baby can feed safely and effectively at the breast and whether this fits your family's feeding goals. If breastfeeding is difficult, a skilled feeding assessment can consider positioning, attachment, milk transfer, milk supply, infant oral function and your baby's ability to coordinate sucking, swallowing and breathing. For more information, see How to Improve your baby's Latch: with Calm, Skilled Feeding Support and Signs of Poor Milk Transfer in Your Baby at Feeds. Bottle feeding with responsive support Bottle feeding is an alternative feeding method in its own right and can be used for expressed breast milk, donor milk where appropriate, or infant formula. Bottle feeding can be occasional, exclusive or part of combination feeding. Using a bottle does not mean that breastfeeding has to stop, and families may use both methods according to their circumstances. Responsive bottle feeding allows your baby opportunities to pause, breathe and communicate whether they want to continue. The bottle can be held relatively horizontally rather than allowing milk to flow continuously into the mouth. Your baby should be held close, with their head and neck appropriately supported and their face visible. Watch their sucking, swallowing, breathing and wider feeding cues rather than focusing only on completing a particular volume. A flow that is too fast for an individual baby may result in coughing, spluttering, gulping, milk leaking from the mouth or difficulty coordinating breathing. A flow that is too slow may result in prolonged sucking, fatigue or frustration. There is no single teat flow or bottle system that is right for every baby. Teat flow labels are not standardised between manufacturers, so the number or name used by a manufacturer does not necessarily tell you how a particular baby will manage that teat. For more information, see How to Pace Bottle Feeds: A Calm Practical Guide. Nipple shields Nipple shields are thin silicone devices placed over the nipple and are sometimes used during breastfeeding. They may be considered in particular circumstances, but they are not a universal solution for latch difficulties and should not automatically be regarded as a way of improving latch. A nipple shield changes the way the nipple and breast tissue are presented to the baby's mouth and can alter the mechanics of milk transfer. Whether one is appropriate depends on the individual feeding situation. If a nipple shield is being considered, it is important to assess why it is being suggested and whether the baby is transferring milk effectively while using it. For more information, see How to Use Nipple Shields. Cup feeding Cup feeding involves offering milk from a small cup rather than using a bottle. Research into cup feeding has particularly involved newborn and preterm infants, often in hospital or neonatal settings. Reviews have found that cup feeding can be a useful alternative method in some circumstances, although the evidence is not sufficient to suggest that it is automatically preferable to other methods for every baby (Flint, New and Davies, 2016; McKinney et al., 2016). Cup feeding can result in more spillage and potentially less milk intake than some other feeding methods. The practicalities also matter, including whether the individual baby can manage the method safely and whether the person feeding has been properly shown how to use it. Cup feeding should therefore not be treated as a simple technique that every family can learn from written instructions. If cup feeding has been recommended for your baby, a trained healthcare professional should assess your baby first and demonstrate the method face to face before you attempt it at home. The evidence base for cup feeding is also particularly important to interpret carefully. Much of the research concerns preterm or neonatal populations, so findings from those settings should not automatically be applied to a healthy term baby at home. Spoon feeding A spoon can sometimes be used to offer small amounts of milk to a baby. Research into spoon feeding has included specific neonatal populations, including low-birth-weight infants. This does not mean that spoon feeding is automatically appropriate for every baby or that research in a neonatal setting provides a general home-feeding recommendation. A spoon should not be used to pour or tip milk into a baby's mouth. If spoon feeding is recommended, the method should be demonstrated face to face by an appropriately trained healthcare professional. The professional should assess whether your baby is suitable for the method and show you how to position your baby, how the milk is offered and how to recognise your baby's cues. This is particularly important because the amount and speed of milk entering the mouth need to be appropriate for the baby's ability to coordinate swallowing and breathing. Supplemental nursing systems and lactation aids A supplemental nursing system, sometimes called a supplemental feeding tube device or lactation aid, allows additional milk to be provided while a baby is breastfeeding at the breast. A small tube is positioned so that milk can flow while the baby remains at the breast. The additional milk may be expressed breast milk or another appropriate milk supplement, depending on the individual feeding plan. This can be an option when a baby needs additional milk but the family would like supplementation to remain closely connected with breastfeeding. Evidence for supplemental feeding tube devices is limited, and research has largely involved specific breastfeeding and neonatal populations. Existing studies suggest that they may be useful for some breastfed infants, but there is not enough evidence to conclude that they are the best supplementation method for every family (Penny et al., 2018). These systems can also require preparation, positioning and cleaning, and the baby's feeding pattern needs to be monitored. If an SNS, Lact-Aid or other lactation aid is being considered, it should be assessed and demonstrated by someone appropriately trained in its use. Where expressing is part of the feeding plan, support with expressing may also be helpful. See the D-Restricted Ltd® blog for Finding the Best Breast Pump for Expressing and Flange Fit Assessment: What Good Fit Considers. The aim is not simply to provide extra milk. The wider feeding plan should consider why supplementation is needed, how milk supply is being supported where this is a goal, and how the feeding method fits with the baby's development and the family's circumstances. Finger feeding Finger feeding involves a baby sucking on a clean finger while milk is provided through an associated feeding device. It has been studied particularly in preterm infants as a way of supporting sucking skills and transition towards breastfeeding. In one randomised study, finger feeding and syringe feeding were compared in preterm infants, but this population is very different from a healthy term baby being fed at home (Buldur et al., 2020). Finger feeding must be demonstrated face to face by an appropriately trained healthcare professional before a family attempts it at home. The professional should assess whether your baby is suitable for the method and show you how the baby should be positioned, how the method is used and how to recognise when the baby needs to pause or stop. Written instructions alone are not sufficient to teach a family how to use finger feeding safely. Syringe feeding A syringe may be used in some clinical circumstances to provide small amounts of milk. It is important to distinguish between a syringe being used as part of an individual feeding plan and treating a syringe as a simple way of delivering a complete feed at home. The amount of milk, the speed at which it is delivered and your baby's ability to coordinate swallowing and breathing all matter. Milk should not be squirted into a baby's mouth or delivered faster than they can comfortably manage. Research comparing syringe and finger feeding has largely involved preterm infants, and evidence from these settings cannot automatically be transferred to healthy term babies at home (Buldur et al., 2020). If syringe feeding has been recommended, the technique should be demonstrated face to face by an appropriately trained healthcare professional, with clear instructions about the volume, pace and circumstances in which it should be used. Enteral tube feeding and hospital-based nutrition Some babies who cannot safely or effectively take enough milk by mouth may need enteral tube feeding, such as a nasogastric tube, which is normally established and monitored by a healthcare team. For babies who are unable to receive sufficient nutrition through the gastrointestinal tract, hospital-based nutritional support such as intravenous nutrition or total parenteral nutrition (TPN) may sometimes be required. These are clinical interventions rather than methods that families should attempt to establish independently at home. Protecting milk supply If maintaining or increasing breast milk production is part of your feeding goals, milk removal is an important consideration. When a baby is not regularly removing milk effectively from the breast, expressing may sometimes be recommended to provide milk for the baby while also giving the breasts additional stimulation and milk removal. This does not mean that every family needs to express. The appropriate plan depends on why an alternative feeding method is being used, the family's feeding goals, the baby's intake and growth, and what is sustainable for the person producing the milk. If expressing is part of your plan, flange fit, pump choice, pump settings, frequency and comfort can all influence the experience. See Finding the Best Breast Pump for Expressing and Flange Fit Assessment: What Good Fit Considers. If you are breastfeeding as well as expressing or providing supplementary milk, it may also be useful to consider whether your baby is transferring milk effectively at the breast. The method that works today may not be the method you need next week An alternative feeding method does not have to become a permanent part of feeding. A baby may move from tube feeding to another method, from cup or spoon feeding to breastfeeding, from supplemental feeding at the breast to exclusive breastfeeding, or from one combination of methods to another as their skills and circumstances change. The method that works today may not be the method your baby needs next week. Reviewing the plan is therefore important. Your baby's age, weight, health, feeding skills, milk intake, growth, hydration and feeding goals can all change. The method may need to change with them. A feeding plan should therefore include consideration of: what method is currently being used why it is being used how much milk is being offered how the baby is managing the method whether the baby is growing and remaining hydrated whether breastfeeding or milk supply needs to be supported what signs would mean that the plan needs review and who should be contacted if concerns arise. Underlying health conditions need individual support The information in this article is primarily relevant to babies who are clinically well enough to feed outside a hospital or specialist clinical setting. Babies with underlying conditions may have additional feeding risks or nutritional requirements. For example, babies with cardiac disease may fatigue more easily or have specific nutritional and fluid requirements. Babies with respiratory conditions may have additional challenges coordinating breathing and feeding. Babies with neurological conditions, significant prematurity or other complex medical needs may also require more specialist assessment and monitoring. In these circumstances, an alternative feeding method should form part of an individual feeding plan developed with the relevant healthcare team. Research involving babies with specific medical conditions can help clinicians understand particular feeding approaches, but it should not be interpreted as a general recommendation for families to use the same method independently at home. Introducing foods is a separate stage Alternative milk-feeding methods are different from introducing complementary foods. Around six months, babies can begin to be offered complementary foods alongside breast milk or infant formula when they are developmentally ready. Milk remains an important part of the diet during the early stages of complementary feeding (World Health Organization, 2023). The introduction of solids therefore needs to be considered separately from decisions about how milk is being provided. No single method is right for every baby Breastfeeding, bottle feeding, nipple shields, cup feeding, spoon feeding, supplemental nursing systems, finger feeding, syringe feeding and tube feeding are all different approaches with different practical considerations. The evidence for many alternative methods comes from specific populations, particularly preterm and hospitalised infants. It is therefore important not to assume that evidence from one group automatically applies to another. The most appropriate method depends on the individual baby and the circumstances in which feeding is taking place. What matters is that your baby is assessed appropriately, that the chosen method is demonstrated to you face to face where required, and that the feeding plan is reviewed as your baby's needs change. Alternative feeding is not one particular technique. It is a range of options that can be considered when the usual route for providing milk is not currently meeting the needs of the baby or family. References Buldur, E., Yalcin Baltaci, N., Terek, D., Yalaz, M., Altun Koroglu, O., Akisu, M. and Kultursay, N. (2020) ‘Comparison of the finger feeding method versus syringe feeding method in supporting sucking skills of preterm babies’, Breastfeeding Medicine, 15(11), pp. 703–708. doi:10.1089/bfm.2020.0043. Flint, A., New, K. and Davies, M.W. (2016) ‘Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed’, Cochrane Database of Systematic Reviews, 2016(8), CD005092. doi:10.1002/14651858.CD005092.pub3. McKinney, C.M., Glass, R.P., Coffey, P., Rue, T., Vaughn, M.G. and Cunningham, M. (2016) ‘Feeding neonates by cup: a systematic review of the literature’, Maternal and Child Health Journal, 20(8), pp. 1620–1633. doi:10.1007/s10995-016-1961-9. Penny, F., Judge, M., Brownell, E. and McGrath, J.M. (2018) ‘What is the evidence for use of a supplemental feeding tube device as an alternative supplemental feeding method for breastfed infants?’, Advances in Neonatal Care, 18(1), pp. 31–37. doi:10.1097/ANC.0000000000000446. World Health Organization (2017) Guideline: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization. World Health Organization (2023) Guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization. UNICEF UK Baby Friendly Initiative (2019) ‘Responsive bottle feeding’. London: UNICEF UK. D-Restricted Ltd® (n.d.) ‘How to improve your baby's latch: with calm, skilled feeding support’. Available at: https://www.tongue-tie.info/post/how-to-improve-infant-latch-practical-breastfeeding-support (Accessed: 16 September 2026). D-Restricted Ltd® (n.d.) ‘How to pace bottle feeds: a calm practical guide’. Available at: https://www.tongue-tie.info/post/how-to-pace-bottle-feeds-a-calm-practical-guide (Accessed: 16 September 2026). D-Restricted Ltd® (n.d.) ‘How to use nipple shields’. Available at: https://www.tongue-tie.info/post/how-to-use-nipple-shields (Accessed: 16 September 2026). D-Restricted Ltd® (n.d.) ‘Flange fit assessment: what good fit considers’. Available at: https://www.tongue-tie.info/post/flange-fit-assessment-what-good-fit-considers (Accessed: 16 September 2026). D-Restricted Ltd® (n.d.) ‘Finding the best breast pump for expressing’. Available from: https://www.tongue-tie.info/blog (Accessed: 16 September 2026).

A feeding consultation should never feel like a conveyor belt towards a procedure. When choosing your tongue-tie practitioner, the most useful question is not simply, “Can they perform a frenulotomy?” It is, “Can they help us understand what is happening with our baby’s feeding, consider the full picture, and support us whichever path feels appropriate?” A visible lingual frenulum is a normal anatomical structure. In some infants, restricted tongue function may be relevant to feeding difficulties; in others, it may not be the main factor, or may not be causing difficulty at all. Feeding can also be affected by positioning, milk flow, breast or chest comfort, bottle teat choice and pacing, infant maturity, health, muscle tone, oral motor coordination and many other factors. Anatomy provides information. Function provides context. This guide is for families seeking care and for professionals signposting them. It focuses on the features of safe, compassionate and evidence-informed practice. Choosing your tongue-tie practitioner starts with assessment A practitioner should be interested in your baby and your feeding experience, not only in the appearance of the mouth. A skilled assessment brings together a relevant health history, observation of feeding where possible, consideration of tongue function and a conversation about the difficulties that matter to your family. For breastfeeding or chestfeeding families, this may include comfort, attachment, milk transfer, feeding frequency, breast or chest changes and the baby’s growth pattern. For bottle-feeding families, it may include dribbling, prolonged feeds, coughing, distress, fatigue, difficulty maintaining a seal or the practical realities of combination feeding. These observations do not confirm tongue-tie on their own. They help build a clinical picture. Ask whether the practitioner will assess feeding function before discussing treatment. If an in-person feed cannot be observed, perhaps because a baby has recently fed or practical circumstances make this difficult, a careful history still matters. The practitioner should explain the limitations and arrange appropriate follow-up where needed. Assessment should also include differential diagnosis: a thoughtful consideration of other possible contributors to the concerns. This does not mean dismissing a caregiver’s experience. It means making sure that care is proportionate, individualised and not based on one finding alone. Look for relevant qualifications, training and accountability Tongue-tie assessment and treatment require specific training, but it is also useful to understand the practitioner’s wider professional background and experience. A practitioner may have undertaken a specific tongue-tie training course and developed substantial experience in this area through their clinical practice. For some practitioners, tongue-tie and infant feeding become a particular area of professional expertise and a long-term vocation. Others may bring additional qualifications and experience from nursing, midwifery, medicine, dentistry, lactation or neonatal care. Rather than assuming that one professional background is automatically better than another, ask what qualifications the practitioner holds, what training they have undertaken and how their experience relates to the care they provide. Consider their infant-feeding knowledge There are different levels of education and professional support within infant feeding and lactation. The Lactation Consultants of Great Britain (LCGB) provides an overview of the different roles involved in breastfeeding support, including peer supporters, breastfeeding counsellors and International Board Certified Lactation Consultants (IBCLCs). LCGB also explains how families can check whether a practitioner is currently an IBCLC through the international registry (LCGB, n.d.). An IBCLC has followed a defined pathway of education, clinical experience and examination specifically relating to lactation and infant feeding. Other practitioners may have substantial infant-feeding knowledge through their professional education, clinical experience and additional training. This does not mean that every tongue-tie practitioner needs to hold an IBCLC qualification. It means that families should be able to understand what level of infant-feeding knowledge their chosen practitioner has and whether this is appropriate to the support they may need. It is also worth asking whether the practitioner undertakes regular update or continuing professional development training. Tongue-tie practice, infant-feeding knowledge, clinical guidance and evidence continue to develop, so maintaining current knowledge is an important part of safe professional practice. For registered nurses and midwives, the NMC Code specifically requires registrants to keep their knowledge and skills up to date through appropriate and regular learning and professional development (NMC, 2018). Other regulated healthcare professionals have their own professional requirements for maintaining competence. A practitioner should also be able to recognise when a feeding difficulty falls outside their own scope of practice and when additional support or referral would be appropriate. Check professional registration where applicable If your practitioner is a registered nurse, dentist or doctor, you can check their professional registration with the relevant regulator: Nursing and Midwifery Council (NMC) General Dental Council (GDC) General Medical Council (GMC) Professional registration does not automatically mean that someone is a tongue-tie specialist. However, it provides a framework of professional standards, accountability and scope of practice. It is therefore reasonable to ask about both the practitioner’s underlying professional qualification and their specific training and experience in tongue-tie assessment, frenulotomy and infant feeding. The Association of Tongue-Tie Practitioners (ATP) also recognises the importance of professional regulation within its membership structure. Its full membership is open to current tongue-tie practitioners who are regulated healthcare professionals registered with the NMC, GMC or GDC and who are registered with CQC or an equivalent regulator where applicable. ATP also has affiliate membership for other professionals involved in tongue-tie and infant-feeding care (ATP, 2026). ATP membership itself is not a statutory requirement for providing tongue-tie services. ATP is a professional association, not the statutory regulator of healthcare professionals. Check CQC registration in England In England, frenulotomy performed by or under the supervision of a healthcare professional falls within the CQC regulated activity of surgical procedures. CQC has specifically confirmed that frenulotomy is a regulated activity because it involves surgical cutting of the lingual frenulum (CQC, 2022). CQC registration is a statutory requirement for providers carrying on a regulated activity. CQC states that it is an offence to carry on a regulated activity without registration where registration is required (CQC, 2022). CQC registration may be held by an individual practitioner or by an organisation or employer through which the service is provided. There may also be arrangements involving practising privileges within a registered service. The important point is that the CQC registration arrangement must appropriately cover the regulated activity being provided. Families can search the CQC website to find the relevant provider or service and check the registered activities. Where an inspection or assessment has taken place, the CQC profile can also provide information about the service and its rating. A CQC rating, where one has been awarded, should also be displayed by the service in accordance with CQC requirements. CQC registration is separate from membership of a professional organisation. For example, membership of ATP is not a legal requirement for providing tongue-tie services, whereas the appropriate CQC registration for the regulated activity of surgical procedures is a legal requirement in England (CQC, 2022; ATP, 2026). Consider the regulatory framework where you live Regulation is not identical across the UK and Ireland. If you are seeking care in Scotland, Wales, Northern Ireland or the Republic of Ireland, check which regulatory framework applies to the practitioner and service in that country. The important principle is to understand what professional registration and regulatory requirements apply to the person providing your baby’s care and to the service in which the procedure is being undertaken. Remember that frenulotomy is a surgical procedure Although frenulotomy may be a relatively quick procedure to perform, this should not be confused with the overall care that surrounds it. A frenulotomy is a surgical procedure and, like any procedure, carries potential risks. The practitioner you choose should therefore have appropriate training and experience not only in performing frenulotomy, but also in recognising and responding appropriately if something does not go as expected. Families can reasonably ask what arrangements are in place for managing unexpected concerns, obtaining further clinical advice and arranging referral or escalation when required. A responsible practitioner should be able to explain the risks in a calm and proportionate way, without either minimising them or unnecessarily alarming families. It is also reasonable to ask how frequently the practitioner performs frenulotomy and how they maintain their knowledge and skills. Experience is not simply about the number of procedures performed; it also includes clinical decision-making, consent, safety, follow-up and knowing when additional assessment or referral is needed. Most importantly, the feeding relationship with the practitioner should not end when the frenulum has been divided. Infant feeding is multifactorial. A frenulotomy may address one anatomical restriction, but it does not automatically resolve every factor contributing to feeding difficulty. Feeding patterns, oral function, positioning, milk flow, infant regulation, muscle tone, coordination, previous feeding experiences and the caregiver’s own experience can all form part of the picture. For this reason, a procedure should be viewed as one part of a feeding journey, not the end of it. A short procedure does not mean that the feeding care surrounding it should be short. Building an understanding of the baby’s feeding, considering what may need to change and supporting the caregiver and infant afterwards may require time and continuity. Ask how treatment decisions are made A frenulotomy may be considered when there is evidence that restricted tongue function is contributing to significant feeding difficulty and when this is discussed within the wider clinical context. It is not an automatic response to a frenulum, feeding discomfort or a referral label. The evidence base is limited by small studies and variation in definitions, assessment and outcomes. A Cochrane review found that frenotomy reduced maternal nipple pain in the short term in the studies available, but evidence for consistent improvement in infant breastfeeding outcomes was less certain (O’Shea et al., 2017). More recent clinical guidance similarly stresses that a restrictive frenulum should be considered in relation to feeding function and within the wider clinical assessment of the breastfeeding dyad (Mehta et al., 2024; Thomas et al., 2021). This does not make caregivers’ difficulties any less real. It means a responsible practitioner should describe what is known, what is uncertain and what alternatives are available. They should be comfortable supporting conservative management, offering feeding support, recommending review, or discussing frenulotomy when it is clinically appropriate and consistent with the family’s informed preferences. Be cautious if you are told that every tongue-tie needs releasing, that a release will definitely resolve all feeding concerns, or that tongue-tie explains a wide range of future difficulties without a careful individual assessment. Equally, a practitioner should not minimise persistent pain, feeding distress or worries about intake simply because a baby is gaining weight. Growth is one important measure, but it is not the whole feeding story. Understand the procedure, method, risks, consent and follow-up If frenulotomy is being considered, it is reasonable to understand how the practitioner carries out the procedure. Different practitioners may use different techniques, and the method used can affect what happens before, during and immediately after the procedure. You can ask: What method do you use for frenulotomy? What, if any, anaesthetic or pain-relief measures are used? What can I expect during and immediately after the procedure? What are the potential risks? What arrangements are in place if an unexpected concern occurs? What aftercare and follow-up are provided? There is no single question about technique that will determine whether a practitioner is right for your family. Understanding the method used simply allows you to make an informed choice and to know what to expect. Our separate guide to tongue-tie division methods explains the different approaches in more detail. Before any procedure, you should have time to ask questions and make a voluntary decision. A clear consent discussion should cover why frenulotomy is being considered, the expected benefits and uncertainties, potential risks, alternatives, what will happen on the day and when to seek further help. The practitioner should also explain whether your baby is eligible for care within their service and whether there are circumstances that require medical review elsewhere. Aftercare is part of the feeding journey Aftercare should not be treated as an optional extra. A frenulotomy may change the available movement of the tongue, but feeding remains a learned and developing process. An infant may need time and appropriate support to adapt to changes in tongue movement and feeding mechanics. Caregivers may also need support as they adjust to changes in feeding. This is particularly important because feeding difficulties are often multifactorial. If several factors have contributed to a feeding problem, addressing one anatomical restriction does not necessarily resolve every aspect of feeding immediately. Ask what follow-up is included, how long it is available for, who you can contact if questions arise and whether ongoing feeding difficulties can be reassessed. A good service should be able to explain what support is available if feeding improves, if progress is slower than expected, or if the original feeding concern continues. Where appropriate, this may involve working alongside your midwife, health visitor, GP, paediatric team or lactation professional. NICE guidance highlights the importance of appropriate training, consent, audit and arrangements for clinical support when tongue-tie division is undertaken (NICE, 2005). Notice how the service communicates The quality of communication can tell you a great deal. Families deserve plain language without alarmist claims, jargon without explanation or judgement about how they feed their baby. A good practitioner will listen to what is hardest, acknowledge uncertainty where it exists and make space for your priorities. This may mean supporting a caregiver who wants to continue breastfeeding or chestfeeding, a family using bottles, someone expressing milk, or those combination feeding. It may mean recognising that an immediate procedure is not right for every baby, and that waiting or seeking another opinion can be reasonable choices. Family-centred care is not about directing families towards one outcome; it is about helping them make informed decisions with skilled support. For some families, practical details matter just as much as clinical expertise. Check where the appointment is held, whether another supporter can attend, what to bring, how long to allow, and how to contact the service afterwards. These details can reduce stress at a time when sleep and confidence may both be in short supply. Questions worth taking to an appointment You do not need to become an expert before seeking help. It can be useful, however, to ask how the practitioner assesses feeding function, what else they will consider, and what support is available if a frenulotomy is not recommended. You might also ask: What professional qualification do you hold? What level of infant-feeding training do you have? What specific tongue-tie training have you undertaken? Do you undertake regular update or continuing professional development training? Are you registered with the NMC, GDC or GMC, where applicable? Is the service appropriately registered with CQC where required? What method do you use for frenulotomy? What anaesthetic or pain-relief measures are used? How do you obtain consent? What follow-up and aftercare are included? What happens if feeding difficulties continue? How can I contact you if I have concerns after the procedure? When would you recommend further assessment or referral? If you leave feeling rushed, unheard or unclear about why a recommendation has been made, it is reasonable to pause and ask for clarification. A second opinion can be particularly helpful where feeding concerns are persistent, the proposed plan feels unclear, or there are other health factors to consider. Choosing a practitioner is about more than the procedure The right practitioner will not promise a particular feeding outcome. They will offer careful assessment, appropriate training, current knowledge, honest discussion, safe care and compassionate support for the next step — whether that involves targeted feeding help, watchful review, referral or a considered frenulotomy. When choosing a tongue-tie practitioner, look beyond the procedure itself. Consider their professional background, level of infant-feeding knowledge, specific tongue-tie training, ongoing education, experience, professional registration where applicable, CQC registration in England and the quality of the clinical governance and aftercare surrounding their service. The procedure may be only one part of the appointment. The relationship that supports your baby’s feeding journey should extend much further. References Association of Tongue-Tie Practitioners (ATP) (2026) Membership Application. Available at: https://www.tongue-tie.org.uk/membership-application (Accessed: 8 September 2026). Care Quality Commission (CQC) (2022) Briefing for providers: Registration requirements for tongue-tie procedures. Available at: https://www.cqc.org.uk/news/providers/briefing-providers-tongue-tie (Accessed: 8 September 2026). Care Quality Commission (CQC) (2025) Surgical procedures. Available at: https://www.cqc.org.uk/guidance-regulation/providers/registration/scope-registration/regulated-activities/surgical-procedures (Accessed: 8 September 2026). General Dental Council (GDC) (n.d.) Standards and guidance. Available at: https://www.gdc-uk.org/standards-guidance/standards-and-guidance (Accessed: 8 September 2026). General Medical Council (GMC) (2024) Good medical practice. Available at: https://www.gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice (Accessed: 8 September 2026). Lactation Consultants of Great Britain (LCGB) (n.d.) Who’s Who in Breastfeeding Support and Lactation in the UK. Available at: https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/ (Accessed: 8 September 2026). Mehta, B., et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2024067605. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE. Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at: https://www.nmc.org.uk/code/ (Accessed: 8 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. Thomas, J., Brodsky, D., et al. (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278–281.

Choosing the right breast pump flange is often presented as simply finding the correct size. In reality, flange fitting is considerably more individualised than this. The part of the breast pump that sits against the breast may be called a breast shield, flange or funnel, depending on the manufacturer and the terminology they use. These terms are often used interchangeably, although technically the component may contain both a flange, which sits against the breast, and a tunnel through which the nipple moves. A good flange fit considers more than nipple diameter. It takes into account the size and shape of the nipple, the shape and geometry of the funnel, the pump being used, the reason for pumping, comfort and how effectively milk is being removed. This matters because a flange can appear to fit when the pump is stationary but behave very differently once pumping begins. Anatomy provides information. Function provides context. What is flange fitting? Flange fitting is the process of identifying the combination of flange size, shape, material and pump configuration that allows the nipple to move comfortably within the tunnel while supporting effective milk removal. The aim is not simply to find a measurement that matches the nipple. The aim is to find a combination that works. Research increasingly supports this more individualised approach. A 2025 pilot study comparing traditional flange sizing with the Flange FITS™ Guide found that participants using smaller-fit flanges had both greater comfort and greater milk yield than when using their usual standard-sized flanges (Anders, Frem and McCoy, 2025). The study is particularly interesting because the average nipple-tip measurement was 12.63 mm, while the standard manufacturer flanges used by participants were 21 mm and 24 mm. The smaller-fit flanges available for the study were 13, 15, 17 and 19 mm, with 15 mm being the most commonly selected size (Anders, Frem and McCoy, 2025). The 12.63 mm figure is a research measurement, not a flange size that can simply be purchased. Flanges are produced in specific increments, so the measurement provides a starting point rather than an automatic answer. The smaller-fit group produced an average of 153.2 g of milk compared with 138.2 g using the standard-fit flanges, while comfort scores were also significantly better (Anders, Frem and McCoy, 2025). This does not mean that everyone should use a smaller flange. It demonstrates why traditional assumptions about flange sizing should not be applied without considering the individual. Size is about the nipple When we talk about flange size, we are talking primarily about the diameter of the nipple and the diameter of the tunnel through which the nipple moves. This is different from the overall size of the breast. The nipple should be able to move comfortably within the tunnel during pumping. It should not rub against the sides of the tunnel, and the flange should not draw areola into the tunnel. The NHS similarly advises that a breast pump should not cause bruising or catch the nipple as it is drawn into the funnel, and recognises that different funnel sizes may be required to fit different nipples (NHS, 2026). However, nipple dimensions are not necessarily fixed. Research has demonstrated measurable changes in nipple diameter and length following milk expression. In one study, nipple horizontal diameter increased by approximately 2.25 mm, vertical diameter by approximately 1.64 mm and nipple length by approximately 2.27 mm following expression (Prime et al., 2023). Nipple dimensions can therefore change with milk removal and other physiological factors, including changes associated with temperature. A measurement taken at one point in the day should not automatically be treated as a permanent measurement. It is also entirely possible for the two nipples to be different sizes. For this reason, there is no requirement for both breasts to use the same flange size. Shape is not the same as size Size and shape are two different considerations. Size relates primarily to the diameter of the nipple tunnel. Shape relates to the geometry of the funnel itself: how wide or narrow it opens, the angle of the flange, the depth and length of the tunnel, and how the funnel interacts with the breast. This distinction is important because two funnels can have the same tunnel diameter but feel and perform very differently. Different breast shapes and tissue characteristics may respond differently to different funnel geometries. Some designs have a narrower, more traditional conical profile, while others have a wider opening angle or a shallower profile. Research supports the importance of this distinction. A randomised controlled trial comparing breast shields with 90° and 105° opening angles found that the wider 105° shield resulted in greater breast drainage, greater milk volume expressed, improved comfort and improved perceived fit (Sakalidis et al., 2020). Shape is therefore not simply an aesthetic variation between manufacturers. Funnel geometry can influence how the breast is loaded during pumping and how effectively milk is removed. There is more than one funnel shape Manufacturers are beginning to recognise that a single funnel geometry cannot accommodate every breast. For example, Maymom currently produces a range of MyFit™ funnels with different designs, including Classic, Crater, Saucer, Comfy and Pano. These differ in opening angle, profile, tunnel length, materials and the way the funnel sits against the breast (Maymom, 2026). This illustrates why simply changing the numerical size of a flange may not solve a fitting problem. If the tunnel diameter is appropriate but the funnel geometry does not suit the breast, changing the size alone may not produce the desired result. The question is therefore not simply "What size flange do I need?" but "Which flange size and shape work with my anatomy and my pump?" The Flange FITS™ Guide The Flange FITS™ Guide represents an important development in moving away from traditional flange-sizing assumptions. The guide provides a structured approach to measuring the nipple and then assessing the fit dynamically during pumping. In the Anders, Frem and McCoy (2025) study, the process began with measuring the nipple tip, selecting the closest available flange size and then trialling sizes approximately one to two sizes above and below that measurement while pumping. The final selection was informed not only by measurement but also by what happened during pumping, including comfort and milk flow. This is an important distinction. The measurement provides a starting point; the fitting process determines what actually works. The study also highlighted that many commercially available pumps have traditionally provided larger standard flange sizes, with 21 mm and 24 mm being common options. The authors noted that empirical support for traditional sizing approaches has been limited and that many major manufacturers have historically offered few options below 21 mm (Anders, Frem and McCoy, 2025). This is beginning to change, but pump manufacturers have not necessarily caught up with the growing evidence around individualised fitting. What does a correctly fitted flange look and feel like? During pumping, the nipple should comfortably glide within the tunnel. Pumping should not be painful. The nipple should not repeatedly rub against the sides of the tunnel, become compressed or show signs of trauma. The flange should not draw areola into the tunnel. The breast should form an effective seal with the flange without excessive pressure. Milk should be able to flow effectively and the pumping experience should be sustainable. The NHS advises starting an electric pump at a low suction setting and increasing gradually, as using high suction immediately may cause pain or damage to the nipple (NHS, 2026). A flange that is technically the correct diameter can still be unsuitable if the shape, positioning, suction or pump settings are not appropriate. Comfort and effective milk removal Comfort and effective milk removal should be considered together. It is not useful to have a flange that produces a large volume of milk if it causes significant pain or nipple trauma. Equally, a flange that feels comfortable but results in poor milk removal may not be meeting the needs of someone who relies on pumping. The research into both flange size and flange design demonstrates that these factors can affect milk removal as well as comfort (Anders, Frem and McCoy, 2025; Sakalidis et al., 2020). This is particularly important for anyone who is pumping frequently, exclusively expressing or using pumping as part of a plan to increase milk production. What if the aim is to increase milk production? Flange fitting can be one part of supporting milk production, but it should not be viewed in isolation. Milk production is influenced by the frequency and effectiveness of milk removal, the physiological response to pumping, pump settings, the individual's circumstances and a range of other factors. If pumping is uncomfortable or milk is not being removed effectively, reviewing the flange may be appropriate. However, a fitting problem is not necessarily the explanation for every low-volume pumping experience. A flange fitting should therefore form part of an assessment rather than become the automatic explanation for reduced pumping output. What about silicone flanges? Silicone and other softer materials are increasingly available as alternatives to traditional rigid plastic funnels. Some silicone products are marketed specifically for people with "elastic nipples". The term "elastic nipple" is not consistently or universally defined, so it should be used cautiously rather than treated as a clearly defined clinical diagnosis. In practice, some people find silicone more comfortable, while others do not. There is also a distinction between marketing claims and clinical experience. In my own clinical practice, I have observed that rigid plastic funnels can sometimes produce better pumping outcomes than silicone alternatives, even where silicone has been marketed as being particularly suitable for "elastic nipples". This is a clinical observation rather than a conclusion established by high-quality comparative research, and individual responses vary. Material therefore needs to be considered alongside size, shape and pump function rather than treated as a universal solution. The pump matters too A flange does not operate independently of the pump. Different pumps have different vacuum characteristics, cycle patterns and operating mechanisms. The same flange may therefore behave differently when used with different pump systems. Pump settings matter too. A higher suction setting is not automatically a more effective setting. The NHS recommends starting at a low suction level and increasing gradually, while remaining within a comfortable range (NHS, 2026). The most effective setting is not necessarily the strongest setting. It is the setting that supports comfortable and effective milk removal for that individual. Replacement parts are not the same as flange fitting A flange can be correctly fitted and the pump can still perform poorly if other components of the pumping system are worn or damaged. Valves, membranes, connectors and other pump components can deteriorate with use. Tubing can also become contaminated or damaged. These components should therefore be checked as part of maintaining pump efficiency, but they should not be confused with flange fitting. A correctly fitted flange cannot compensate for a worn valve, damaged membrane or other component that is affecting the performance of the pump. If milk or condensation enters tubing, or if tubing becomes contaminated or damaged, the manufacturer's instructions should be followed regarding cleaning or replacement. Cleaning and sterilising Cleaning and sterilising are separate considerations from flange fitting, but they remain essential when expressing human milk. The NHS advises that pumps and their components should be clean and sterilised before use and that the pump and parts should be washed and sterilised after expressing (NHS, 2026). Always follow the manufacturer's instructions because different pump systems have different requirements and not every component is designed to be sterilised in the same way. Tubing does not normally come into contact with milk and is therefore not routinely sterilised in the same way as milk-contact components. If milk, moisture, mould or other contamination enters the tubing, the manufacturer's instructions should be followed and replacement may be necessary. The Parent Home FITS™ Guide The Flange FITS™ approach is not intended to stop at the point where a flange has been selected. The Parent Home FITS™ Guide provides practical support for caregivers to continue assessing their pumping experience at home, with particular attention to comfort and milk removal. This is important because flange fitting is not necessarily a one-time event. Nipple dimensions can change. Breast tissue can change. Pumping patterns can change. A person may also move between different pumps or different pumping situations. The flange that worked well several months ago may therefore not remain the best option indefinitely. The purpose of an individualised fitting process is not simply to give someone a flange size. It is to help them understand what a good fit looks and feels like so that they can recognise when something changes. When flange fitting is not the answer Not every pumping problem is caused by flange size or shape. Pain, low milk volume, reduced milk removal, nipple trauma or difficulty expressing may have multiple contributing factors. The pump itself, suction and cycle settings, breast fullness, milk ejection, pumping technique, frequency of expression and individual physiology may all need to be considered. This is why a flange fitting should not be treated as a quick online measurement exercise. For someone experiencing ongoing difficulties, an assessment by an IBCLC with specific lactation and pumping expertise can provide a more individualised evaluation of the whole pumping system. The goal is not to sell a smaller flange. The goal is to identify what allows this individual to pump comfortably and remove milk effectively. Moving beyond the traditional 24 mm flange For many years, 24 mm has been presented as a standard flange size supplied with breast pumps. That does not mean that 24 mm is the correct size for everyone. The research underpinning the Flange FITS™ Guide demonstrates how different the individual measurements of nipples can be and how much difference flange selection may make to comfort and milk removal (Anders, Frem and McCoy, 2025). The average nipple-tip measurement in that study was 12.63 mm, while the smaller-fit flanges available to participants ranged from 13 to 19 mm. The most frequently selected smaller-fit size was 15 mm (Anders, Frem and McCoy, 2025). This is one reason why a manufacturer's supplied flange should be viewed as a starting point rather than proof that it is the correct size. The same principle applies to shape. A 24 mm flange with one funnel geometry may behave very differently from a 24 mm flange with another. Flange fitting is individual There is no single flange size that works for everyone. There is no single funnel shape that works for everyone. There is no single material that works for everyone. And there is no guarantee that the same flange will remain appropriate throughout the expressing journey. A useful fitting process considers: nipple diameter nipple shape changes during pumping left and right differences funnel geometry breast shape and tissue flange material pump compatibility pump settings comfort milk flow milk removal the reason the person is pumping and the condition of the wider pump system The emerging evidence around the Flange FITS™ Guide reinforces the importance of moving away from a one-size-fits-all approach (Anders, Frem and McCoy, 2025). Anatomy provides information. Function provides context. For anyone experiencing ongoing difficulties with pumping, an individualised assessment can be far more useful than simply measuring the nipple and ordering the nearest available flange. The right fit is the one that works. 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. Maymom (2026) MyFit™ breast pump flange/funnel range. Available from: Maymom. [Accessed 3 September 2026]. NHS (2026) 'Expressing and storing breast milk'. NHS. Available from: NHS website. [Accessed 3 September 2026]. NHS (2026) 'Expressing breast milk with a pump'. NHS Best Start in Life. Available from: NHS website. [Accessed 3 September 2026]. Prime, D.K. et al. (2023) 'Human milk expression technologies: an evaluation of efficacy and comfort of hands-free, in-bra, breastmilk collection pump set', Clinical Nutrition Open Science, 49, pp. 1–14. Sakalidis, V.S. et al. (2020) 'Breast shield design impacts milk removal dynamics during pumping: A randomized controlled non-inferiority trial', Acta Obstetricia et Gynecologica Scandinavica, 99(11), pp. 1561–1567. doi: 10.1111/aogs.13897.

A good tongue-tie training course should leave a practitioner more able to sit with complexity, not more eager to label every feeding difficulty as an oral restriction. Families often arrive after a difficult start, having heard conflicting advice and wanting a clear explanation. They deserve clinicians who can assess anatomy thoughtfully, understand feeding function and keep the whole feeding relationship in view. For healthcare professionals, choosing education in this area is therefore not simply about learning terminology or becoming familiar with images of oral anatomy. It is about developing the judgement to recognise when tongue mobility may be relevant, when other factors need attention first, and when specialist assessment or collaborative care is appropriate. What should a tongue-tie course teach? The most valuable learning begins with a clear distinction between appearance and function. The lingual frenulum is a normal anatomical structure, and variation in its appearance is common. Its presence, prominence or point of attachment does not, by itself, establish that it is causing a feeding problem. This distinction matters because infant feeding is dynamic. Breastfeeding, chest/body feeding and bottle feeding can be influenced by positioning, attachment, milk flow, infant tone, gestation, health, parental comfort, feeding frequency, breast or chest anatomy, bottle-feeding pace and family circumstances. Oral function may be one part of the clinical picture, but it is rarely the whole picture. The Academy of Breastfeeding Medicine advises that a restrictive lingual frenulum should be considered a functional diagnosis, and that no assessment tool should be used as the sole basis for deciding whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). A course should help learners understand why this matters in practice: a score, a photograph or a visual finding cannot replace a skilled feeding history, observation and discussion with the family. High-quality education should cover infant oral anatomy and development, the relationship between tongue movement and feeding, principles of feeding assessment, differential diagnosis, conservative management and appropriate referral pathways. It should also address the evidence and uncertainties around frenulotomy, including aftercare and continuity of feeding support. Crucially, education for infant feeding professionals is not the same as procedural training. A responsible course can explain the clinical considerations around surgical release without teaching learners how to perform a procedure. Understanding the assessment tool: supporting, not replacing, clinical assessment Understanding the assessment tool being used is an important part of appropriate training. Practitioners need to know what the tool is designed to assess, how its individual components should be interpreted, and, importantly, what its limitations are. An assessment tool can provide a structured way of documenting observations and identifying areas that may warrant further consideration, but it should not be treated as a diagnostic test. A score or finding within an assessment tool does not, on its own, establish a diagnosis of tongue-tie. Diagnosis is part of a holistic clinical assessment undertaken during consultation, bringing together the infant’s anatomy and oral function with feeding observations, symptoms, history, growth, the caregiver’s concerns and the wider clinical picture. Other potential explanations for the presenting concerns must also be considered. This is why training should not simply teach practitioners how to complete an assessment tool. It should help them understand the reasoning behind the tool, what its findings can and cannot tell them, and how those findings contribute to a wider clinical assessment. For example, nipple pain may occur alongside restricted tongue movement, but pain alone does not establish causation. Equally, an infant who is gaining weight may still be experiencing difficult, inefficient or uncomfortable feeds. Both the observable clinical information and the caregiver’s account form important parts of the consultation. An assessment tool therefore provides information and structure; it does not replace clinical judgement or the consultation itself. Anatomy provides information. Function provides context. Clinical assessment brings the whole picture together. Evidence should be taught with its limits Tongue-tie training should present research accurately, including what studies can and cannot tell us. Systematic review evidence suggests that frenulotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains limited and studies have important methodological constraints (O’Shea et al., 2017). More recent clinical guidance similarly stresses comprehensive feeding assessment and careful selection rather than intervention based on anatomy alone (American Academy of Pediatrics, 2024). This does not mean that feeding difficulties should be minimised. It means decisions need to be individualised, with the potential benefits, limitations and uncertainties discussed honestly. A balanced course should also explain that evidence is not evenly developed across all claimed associations with tongue-tie. Where evidence is limited, emerging or absent, practitioners should be able to say so clearly. This is especially important when families have encountered broad claims linking oral ties with future speech, sleep, dental, posture or developmental concerns. These issues require their own appropriate assessment and should not be predicted from a tongue-tie finding alone. Learning to communicate uncertainty is a clinical skill, not a gap in expertise. Families can make better decisions when they understand both the reasons for a recommendation and the limits of what can be promised. How to evaluate a tongue-tie course Before enrolling, look beyond the course title. Consider who developed the content, whether it is grounded in current evidence and whether the learning encourages reflection rather than a single pathway. The educator’s clinical experience can be valuable, but experience should sit alongside transparent evidence use and clear professional boundaries. A thoughtful programme will make space for the practical realities of care. It should include feeding observation, history taking, documentation, consent, safeguarding, communication and referral. It should acknowledge that a family may choose conservative support, specialist review, frenulotomy where clinically appropriate, or a different feeding plan altogether. The role of the practitioner is to offer respectful, accurate information and skilled support, not to direct a family towards a predetermined outcome. For practitioners supporting bottle-feeding families, this breadth is equally relevant. Bottle-feeding challenges can involve feeding rhythm, teat flow, positioning, infant coordination, discomfort and other health factors. A course focused solely on breastfeeding, or solely on oral anatomy, may leave important gaps in care. It is also worth asking how a course handles disagreement. The field includes differing terminology, assessment approaches and views on management. Education should not hide this. Instead, it should help learners appraise claims, understand the quality of evidence and work collaboratively within their scope of practice. Questions worth asking before you enrol You may find it useful to ask whether the course explains differential diagnosis, includes both conservative and surgical considerations, teaches how to discuss uncertainty, and sets out clear referral and scope-of-practice boundaries. Also ask whether teaching is updated as evidence develops and whether learners can apply the material to realistic case discussions rather than relying on images or scores in isolation. It is also worth considering who is providing the training. Look for a course delivered by an experienced provider with relevant clinical and educational expertise, and consider whether the course is accredited or recognised by an appropriate professional or educational body. Accreditation can provide reassurance about the educational framework, while the provider’s experience can help ensure that assessment tools and clinical information are presented within the context of real-world practice. A certificate alone, however, should not be taken as evidence of competence to diagnose or treat. For many professionals, accessible online learning is a practical starting point. It works best when it is structured, evidence-informed and designed to support reflection between modules. Opportunities to revisit content can be particularly helpful, because clinical reasoning develops over time and through experience. From education to family-centred practice The value of education is seen in the consultation room. A well-prepared practitioner listens without assuming, observes without rushing and explains findings in language a family can use. They can say, for instance, that a frenulum may be contributing to the feeding picture while also considering attachment, milk transfer, infant wellbeing and the parent’s goals. Where a specialist assessment is needed, families should understand why. Where skilled feeding support may help, that support should not be treated as a lesser option. The National Institute for Health and Care Excellence notes that evidence on the efficacy of division of ankyloglossia for breastfeeding is limited, while recognising that the procedure has no major safety concerns when undertaken by appropriately trained practitioners with suitable arrangements for care (NICE, 2005). This reinforces the need for careful assessment, informed consent and follow-up rather than a one-size-fits-all response. For learners seeking this depth, Tongue-tie School is designed around infant oral anatomy, tongue function, assessment principles, differential diagnosis, oral activities, conservative management, surgical-release considerations and aftercare. Its focus is on evidence-informed clinical reasoning and family-centred care, not on teaching surgical technique. The right course will not give every case a simple answer. It will help you offer something more useful: calm, skilled and compassionate care that keeps each baby, each feed and each family’s priorities at the centre. D-Restricted Ltd's Tongue-tie School®: professional education for healthcare professionals For healthcare professionals wanting to develop their understanding of infant tongue-tie, oral function and the wider considerations surrounding feeding and treatment, D-Restricted Ltd's Tongue-tie School® offers structured, evidence-informed professional education. The programme, Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations, has been developed for professionals supporting infants and families, including Registered Nurses, Midwives, Health Visitors, International Board Certified Lactation Consultants (IBCLCs), lactation and infant-feeding specialists, speech and language therapists and other allied healthcare professionals. It is also suitable for existing tongue-tie providers who wish to refresh and consolidate their knowledge. The course takes a function-based approach, recognising that understanding infant tongue-tie involves more than identifying an anatomical variation. It explores the relationship between oral anatomy, tongue movement, feeding skills, oral function, infant regulation and the wider infant–caregiver feeding dyad. The aim is to help professionals develop a broader understanding of the factors that may contribute to feeding difficulties and how these should be considered when supporting individual families. What will you learn? The programme is structured across six modules: Module 1: Anatomy and Physiology Develop an understanding of relevant oral anatomy and physiology, including the tongue, oral cavity and surrounding structures, and their relationship to infant feeding function. Module 2: Potential Impact of Oral Ties and Functional Considerations Over Time Explore the potential relationship between oral ties, function and feeding experiences, while recognising individual variation and the importance of considering the wider clinical picture. Module 3: Tongue Function Assessment Tools and Differential Diagnosis Explore awareness of tongue-function assessment approaches and the role of assessment tools within clinical practice. The module considers the importance of interpreting findings alongside a comprehensive assessment of the infant–caregiver feeding dyad and considering other possible explanations for presenting difficulties. Module 4: Body Therapies, Tongue Exercises and Sensorimotor Oral Activities Consider supportive approaches including body therapies, oral play and exercises, and their potential role within preparation, rehabilitation and ongoing infant-feeding support. Module 5: Surgical Release Procedures: Methods, Risks and Clinical Considerations Explore considerations surrounding frenulotomy, including informed decision-making, potential risks, preparation of the infant–caregiver feeding dyad and the importance of appropriate aftercare. Module 6: Conservative Management and Ongoing Care Consider conservative management, ongoing support and rehabilitation approaches, including the importance of multidisciplinary working and supporting the infant–caregiver feeding dyad throughout their feeding journey. Online and self-paced D-Restricted Ltd's Tongue-tie School® is delivered as an online, self-paced, on-demand programme, allowing professionals to work through the material alongside their existing clinical and professional commitments. The programme contains six structured video-based modules with supporting resources, knowledge-review quizzes and a reflective case study. Learners have ongoing access to the course materials and there is no requirement to complete the programme within a rigid timeframe. The recommended minimum completion period is four weeks, with approximately 10 hours of study plus additional reading and self-directed learning. Each module includes a knowledge assessment, with learners required to achieve a minimum 80% pass mark for each quiz. A reflective case study is also submitted, encouraging learners to consider an infant-feeding journey holistically, including assessment considerations, possible treatment options, referral pathways, follow-up and ongoing support. Successful completion provides both a Certificate of Online Attendance and a Certificate of Accreditation. Accreditation and CPD D-Restricted Ltd's Tongue-tie School® is accredited by Advantage and has been awarded 15 CPD points. The programme has also been awarded 8 L-CERPs by IBLCE for IBCLCs. Learning from an experienced provider When selecting professional education, accreditation is one factor to consider, but it is also worth looking at who has developed and delivers the programme and what experience they bring to the subject. D-Restricted Ltd's Tongue-tie School® was developed by Diana Warren RGN, IBCLC, founder of D-Restricted Ltd®, drawing on her neonatal nursing background, specialist infant-feeding practice and extensive clinical experience supporting infants and families where she has achieved an OUSTANDING ranking from the Care Quality Commission (CQC). She is also a Trustee of the Association of Tongue-tie Practitioners (ATP) in the UK. This combination of clinical experience and professional education is important because tongue-tie cannot be adequately understood through anatomy or assessment scores alone. Experienced teaching can help place assessment findings, feeding difficulties, treatment considerations and ongoing support into their appropriate clinical context. Continuing professional connection Learning does not necessarily stop when the final module is completed. D-Restricted Ltd's Tongue-tie School® also provides access to a community support hub, giving participants an opportunity for ongoing professional connection, discussion, resource sharing and peer learning beyond the structured course content. For professionals who want to develop a deeper understanding of infant tongue-tie while recognising the importance of function, feeding and the wider clinical picture, D-Restricted Ltd's Tongue-tie School® provides a structured opportunity to build knowledge, reflect on practice and continue learning over time. Anatomy provides information. Function provides context. Clinical assessment brings the whole picture together. For further information on the course or to enrol please visit https://www.tongue-tie.info/school References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. American Academy of Pediatrics (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2024067605. National Institute for Health and Care Excellence (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. et al. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065.

A visible lingual frenulum, the band of tissue beneath the tongue, can prompt understandable questions when feeding is painful, prolonged or worrying. Yet the question, when should a tongue-tie release be considered?, cannot be answered by appearance alone. In UK infant care, the procedure is more accurately called a frenulotomy. The most helpful decision is based on how the baby feeds, how the feeding parent is coping, what skilled support has already been offered and what matters to the family. Anatomy provides information. Function provides context. Some babies with a restricted lingual frenulum feed comfortably and effectively, while others experience genuine feeding difficulty. Equally, feeding challenges are common and can have more than one cause. A careful, compassionate assessment helps avoid both missed support and unnecessary intervention. When should frenulotomy be considered? Frenulotomy may be considered when an infant has a restrictive lingual frenulum and there is a clear, ongoing functional feeding difficulty that has not improved sufficiently with skilled feeding support. This is not a decision that should rest on a photograph, an oral examination in isolation or a checklist score alone. For a breastfeeding or chestfeeding dyad, relevant concerns may include persistent nipple pain or damage, difficulty achieving or maintaining an effective latch, concerns about milk transfer, unsettled feeding behaviour or feeds that remain difficult despite appropriate support. A baby’s growth pattern, hydration, output, feeding history and the parent’s experience all need to be understood together. For bottle-fed babies, assessment should similarly begin with function rather than assumptions. Families may describe difficulty maintaining a seal, milk loss, coughing, frequent pauses, fatigue during feeds or distress. These signs are not specific to tongue-tie. Flow rate, teat shape, feeding pace, positioning, health factors and a baby’s wider oral-motor development may also be relevant. A frenulotomy is therefore a possible component of care, rather than a default response to a frenulum. The Academy of Breastfeeding Medicine (2021) advises that the presence of a sublingual frenulum alone is not an indication for intervention, and that decisions should be made following a skilled breastfeeding assessment. What feeding symptoms might suggest a problem? If you are wondering whether your baby’s tongue-tie may be affecting feeding, it can be helpful to look at what is actually happening during a feed rather than focusing on how the frenulum looks. Breastfeeding or chestfeeding Parents may notice: persistent nipple pain or damage difficulty achieving or maintaining a deep, comfortable latch frequent slipping on and off the breast clicking or loss of suction during feeds milk leaking from the sides of the mouth very long or very frequent feeds a baby who appears unsettled or frustrated during feeds difficulty managing the flow of milk coughing, spluttering or difficulty coordinating sucking, swallowing and breathing concerns about milk transfer breasts that remain very full after feeds a baby who seems to tire before completing a feed concerns about weight gain or feeding efficiency. For the breastfeeding parent, ongoing pain, nipple compression or damage can be particularly important clues that feeding mechanics need closer assessment. However, none of these symptoms proves that a baby has a tongue-tie. Feeding is complex, and similar symptoms can occur for many different reasons. Bottle feeding Bottle-fed babies can experience difficulties that may prompt an assessment of oral function. These can include: difficulty maintaining a seal around the teat milk leaking from the mouth clicking or loss of suction coughing, spluttering or choking during feeds difficulty controlling the flow of milk frequent pauses or stopping and starting taking a very long time to finish a bottle becoming fatigued during feeds distress or frustration while feeding difficulty coordinating sucking, swallowing and breathing crushing or chewing the teat repeatedly pushing the teat out with the tongue difficulty maintaining a consistent sucking rhythm. Again, these symptoms are not specific to tongue-tie. Teat shape and flow rate, bottle positioning, feeding pace, oral-motor development, coordination, prematurity, illness and other factors can all affect how a baby feeds. Other feeding behaviours to notice Parents may also notice clicking or noisy feeds, frequent short or “snack” feeds, feeding frustration, gagging or retching, frequent spit-up, trapped wind, or a baby who seems to work very hard or become tired while feeding. These signs can be useful information to share with a feeding specialist, particularly when several occur together or feeding remains difficult despite appropriate support. They should not, however, be interpreted as a list of symptoms that automatically means a tongue-tie is present. What else could be causing the feeding difficulties? Feeding symptoms can have many different causes, and sometimes there may be more than one factor involved. A baby who is struggling to feed does not necessarily have a tongue-tie, even if a frenulum is visible. For example, breastfeeding difficulties may be influenced by positioning and attachment, milk supply or flow, breast fullness, nipple pain or damage, oral thrush, infant body tension, prematurity, illness or other medical factors. With bottle feeding, teat shape and flow rate, bottle positioning, feeding pace, oral-motor development and coordination of sucking, swallowing and breathing may all have an impact. This is why it is important to ask “what else could be influencing these symptoms?” rather than assuming that every feeding difficulty is caused by a tongue-tie. My tongue-tie symptom checker can help parents identify and record feeding signs that may be worth discussing with an infant feeding specialist. It can be particularly useful for helping you describe what you are seeing during feeds and how feeding is affecting you and your baby. The symptom checker cannot diagnose tongue-tie. The symptoms listed can occur for many different reasons, and having several of them does not mean that your baby has a restrictive tongue-tie. (https://www.tongue-tie.info/tongue-tie-symptom-checker) Why specialist feeding assessment matters If you are concerned about your baby's feeding, specialist infant feeding support is an important first step. For breastfeeding or chestfeeding, an International Board Certified Lactation Consultant (IBCLC) is the gold-standard specialist qualification for lactation support and can assess the feeding process in detail. A thorough assessment should look at the whole feeding dyad, rather than simply examining the baby's mouth. This includes observing a feed, listening to the parent's experience, considering the baby's feeding history and growth, and assessing how the tongue moves and functions during feeding. Functional assessment of tongue motility is particularly important. The question is not simply whether a frenulum is present, or whether it looks tight, but whether the tongue can move effectively enough for the baby to feed efficiently and comfortably. Most practitioners who assess tongue-tie will use a structured assessment tool to help them with this process. These tools can be useful because they provide a consistent framework for looking at the frenulum and aspects of tongue function. However, an assessment tool is a tool — it is not a diagnosis. A score should never be used on its own to decide that a baby has a tongue-tie or needs a frenulotomy. The baby needs to be assessed by a suitably trained clinician who can interpret the assessment tool alongside functional tongue movement, feeding observations, the baby's symptoms, the parent's experience and any other factors that may be influencing feeding. A photograph cannot diagnose a restrictive tongue-tie. Neither can a checklist score, an online symptom checker or an opinion based on the appearance of the frenulum alone. The aim of a good assessment is to understand the whole picture: What symptoms are happening now? What else could be influencing them? How is the baby's tongue functioning? And is there evidence that a restrictive frenulum is contributing to the feeding difficulty? Only once those questions have been considered can frenulotomy be appropriately discussed. Most importantly, assessment should focus on the baby's current function and current symptoms, rather than what a frenulum might theoretically cause in the future. Frenulotomy should not be undertaken simply because a frenulum is visible, looks unusual or receives a particular score. The decision should be based on a clear functional problem and a considered assessment of whether releasing the frenulum is likely to provide meaningful benefit. What does a function-focused assessment involve? A good assessment takes time. It begins by listening: what is happening in real feeds, when did the difficulty begin, what support has been tried, and what impact is this having on the family? Observing a feed, where appropriate, can provide information that cannot be gained from looking in a baby’s mouth alone. The clinician will consider tongue movement and oral anatomy alongside feeding mechanics, comfort, milk transfer where relevant and the baby’s overall wellbeing. They may also consider factors outside the mouth. Breast or chest fullness, engorgement, nipple anatomy, positioning, attachment, supply concerns, infant prematurity, reflux-like symptoms, illness, neurological differences or birth-related tension can each affect feeding. Sometimes several small factors are interacting. For professionals, this is where clinical reasoning matters. Assessment tools can help structure observation and communication, but they do not independently diagnose a feeding problem or determine that a procedure is required. A score should support, not replace, a comprehensive history and functional assessment. Conservative support may be the right first step Many families benefit from individualised feeding support before deciding whether a frenulotomy is appropriate. This might include adjustments to positioning and attachment, responsive feeding guidance, help protecting milk production when transfer is a concern, or practical bottle-feeding support. The aim is not to delay necessary care, but to establish whether difficulties improve when modifiable factors are addressed. Conservative management is also a valid choice when feeding is comfortable, the baby is thriving and the family does not wish to pursue a procedure. Choosing observation and support is not ‘doing nothing’. It is an active plan that should include clear advice about what to monitor and when to seek further help. What does the evidence say? The evidence base supports a measured discussion. A Cochrane review of randomised trials found that frenulotomy reduced maternal nipple pain in the short term. However, the trials were small, and evidence for consistent improvement in infant breastfeeding effectiveness or longer-term breastfeeding outcomes was limited (O’Shea et al., 2017). More recent guidance reaches a similar conclusion. The American Academy of Pediatrics (2024) notes that evidence suggests a short-term reduction in nipple pain for some breastfeeding parents, while evidence for longer-term breastfeeding outcomes remains limited. The FROSTTIE trial in the UK was affected by recruitment challenges and substantial crossover between groups, meaning it could not provide a definitive answer about breastfeeding continuation at three months (Knight et al., 2023). This does not mean that families who report meaningful improvement after frenulotomy are mistaken. It means outcomes vary, research has limitations and clinicians should communicate uncertainty honestly. A procedure may help some dyads where restriction is contributing to feeding difficulty; it cannot be expected to resolve every feeding concern. Evidence relating to outcomes beyond infant feeding, including future speech, sleep, dental development or posture, is insufficient to justify an infant frenulotomy in the absence of current functional feeding concerns. Families deserve reassurance that there is rarely a need to make a rushed decision based on predictions about the future. Shared decision-making: benefits, limits and risks When a frenulotomy is being considered, families should have space to discuss the likely benefits, the uncertainties and the alternatives. They should understand what support will be available before and after any intervention, and how feeding will be reviewed afterwards. Continuity matters, because a procedure addresses tissue restriction but does not automatically resolve learned feeding patterns, supply concerns or the emotional toll of difficult feeds. Frenulotomy is generally regarded as a minor procedure when undertaken by an appropriately trained and experienced practitioner in a suitable clinical setting. Nevertheless, it is not risk-free. Possible complications include bleeding, pain, infection, oral aversion, feeding disruption and the need for further assessment or care. Serious complications are uncommon but have been reported, particularly where care is delayed or undertaken outside appropriate clinical pathways (NICE, 2005; Academy of Breastfeeding Medicine, 2021). Families should not feel pressured either towards or away from intervention. A parent who has reached a point of significant pain, exhaustion or distress needs timely, respectful care. Equally, a family whose baby is feeding well should not be made anxious by the appearance of normal anatomical variation. When referral for specialist assessment is helpful Specialist infant feeding and tongue-tie assessment can be valuable where feeding remains difficult despite initial support, where there is uncertainty about whether tongue function is contributing, or where parents need an informed discussion of their options. Urgent medical assessment is needed if a baby is showing signs of dehydration, poor weight gain, lethargy, persistent vomiting, breathing difficulty or illness. For families considering a frenulotomy, it is reasonable to ask who will assess feeding, how other causes of difficulty will be considered, what evidence informs the recommendation, and what follow-up is available. At D-Restricted Ltd®, assessment and aftercare are structured around the individual baby, the feeding relationship and the family’s goals, rather than anatomy alone. A decision about frenulotomy should leave a family feeling heard, informed and supported. Whether the next step is skilled feeding help, careful observation, further medical review or a procedure, the right pathway is the one that responds to the baby in front of you and the realities of that family’s feeding journey. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. American Academy of Pediatrics (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 153(2), e2024067605. Knight, M., Ramakrishnan, R., Harper, P. 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. 1-68. National Institute for Health and Care Excellence (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE. O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065.

A visible fold of tissue beneath a baby’s tongue or upper lip can prompt understandable questions, particularly when feeding is painful, tiring or worrying. Yet a tongue-tie and lip-tie restrictions are not a simple comparison of two pieces of anatomy. What matters clinically is whether an oral structure appears to be affecting function within the wider feeding relationship. For families, this distinction can reduce pressure to find one explanation for every feeding difficulty. For healthcare professionals, it supports careful differential diagnosis and avoids treating appearance as a diagnosis. Anatomy provides information. Function provides context. What is a tongue-tie? Tongue-tie, also known as ankyloglossia, describes a lingual frenulum that restricts the movement of the tongue. The lingual frenulum is the fold of tissue connecting the underside of the tongue with the floor of the mouth. It is a normal anatomical structure, but its appearance, attachment and effect on tongue movement vary considerably between infants. Tongue-ties do not all look the same. Some frenula are thin and barely visible, while others are thicker, more prominent or attach in a different position. However, the appearance of the frenulum is not the diagnosis. The important question is what the tongue can actually do and whether any restriction is associated with meaningful functional difficulties. This is particularly important when considering infant feeding. A visible or prominent frenulum does not automatically mean that a baby has a clinically significant tongue-tie. Equally, the appearance of the frenulum alone cannot tell us how well the tongue is functioning. When assessing a baby with feeding difficulties, the whole feeding picture needs to be considered. In breastfeeding, this may include ongoing nipple pain or damage, difficulty maintaining attachment, clicking, milk leakage, prolonged or unsettled feeds, or concerns about milk transfer and weight gain. These signs are not specific to tongue-tie and can have many other causes, including positioning and attachment, breast fullness, milk supply, prematurity, jaundice, illness, oral or neurological differences and the normal learning process of early feeding. For bottle-fed babies, difficulties such as losing the seal, dribbling milk or taking a long time to feed can also have many explanations. Teat flow, feeding pace, bottle angle, positioning and other medical or developmental factors should be considered rather than assuming that a frenulum is responsible. The American Academy of Pediatrics (AAP), in its 2024 clinical report, recommends that symptomatic ankyloglossia should be considered in the context of a restrictive lingual frenulum associated with significant feeding difficulties that have not improved with appropriate support. Not every baby with a tongue-tie requires treatment, and assessment of feeding and tongue function should come before considering frenotomy. (AAP, 2024) Most importantly, assessment should focus on what is happening now. A frenulum should not be released simply because someone believes it might cause a problem with speech, teeth, sleep or other functions years into the future. The decision should be based on demonstrable restriction and symptoms that are present and clinically relevant at the time of assessment. What is a lip-tie? A “lip-tie” usually refers to the maxillary labial frenulum — the band of tissue connecting the inside of the upper lip with the gum. This is a normal oral structure that is present in infants and changes naturally as a child grows. There is considerable normal variation in the appearance and attachment of the upper labial frenulum. Some babies have a frenulum that looks prominent, thick or attaches relatively low on the gum. This does not, by itself, mean that the upper lip is functionally restricted or that treatment is required. Importantly, the appearance of the upper labial frenulum should not be used to diagnose an infant feeding problem. The American Academy of Pediatrics (AAP) states in its 2024 clinical report that labial and buccal frenula are normal oral structures and that surgical intervention on these tissues to improve breastfeeding is not supported by evidence. (AAP, 2024) In the UK, upper lip frenula are not routinely divided in infancy, and there is no good evidence that doing so improves breastfeeding. The biggest clinical considerations relating to the upper labial frenulum are generally associated with dental development or aesthetics later in childhood or adulthood, rather than infant feeding. This is an important distinction. A prominent upper lip frenulum in a newborn does not mean that it needs to be treated in anticipation of a possible future dental problem. If there is a genuine dental concern as the child grows, it can be assessed in the context of the developing dentition. Where assessment or treatment is being considered, particularly once the adult teeth have erupted, an appropriately trained paediatric oral surgeon or specialist dentist is the appropriate professional to assess the anatomy and its clinical significance. What about lower lip-ties and buccal-ties? Lower lip frenula and buccal frenula — the tissues connecting the lips or cheeks to the gums — are also normal anatomical structures. There is no established evidence that releasing these tissues in infancy improves breastfeeding or other infant feeding outcomes. These structures should therefore not be treated as additional “ties” that need to be identified and divided simply because they are visible. Their presence or appearance does not demonstrate a feeding problem, and routine division of multiple oral frenula in infants is not supported by good evidence. Tongue-tie vs lip-tie: what is the difference? Although the terms “tongue-tie” and “lip-tie” are often discussed together, they describe different anatomical structures and should not be treated as though they have the same evidence behind them. A tongue-tie involves the lingual frenulum beneath the tongue. In some infants, a restrictive lingual frenulum can contribute to impaired tongue movement and, alongside other factors, may be associated with breastfeeding difficulties. The evidence for treatment remains limited, but there is evidence that frenotomy can reduce maternal nipple pain in carefully selected cases where significant functional problems persist despite appropriate feeding support. The AAP's 2024 clinical report therefore emphasises careful assessment and conservative management before considering surgical intervention. (AAP, 2024) A lip-tie, by contrast, refers to the maxillary labial frenulum beneath the upper lip. This is a normal structure, and there is currently no good evidence that its appearance causes infant feeding difficulties or that releasing it improves breastfeeding. The same applies to lower lip and buccal frenula: their appearance does not establish a functional feeding problem and routine release in infancy is not evidence-based. The key distinction is therefore not simply tongue versus lip, but function versus appearance. Frenula naturally look different from one infant to another. Some are prominent, some are subtle, and their attachments vary. What matters clinically is not whether a frenulum looks unusual, but whether there is a demonstrable functional restriction and whether that restriction is reflected in the infant's current symptoms and feeding function. Assessment should therefore ask: What does the tissue look like? What can the tongue or lip actually do? Is there a demonstrable functional problem? Are there feeding symptoms that are present now? What other explanations could account for those symptoms? Has appropriate non-surgical feeding support been provided where relevant? Is there good evidence that releasing the tissue is likely to provide a meaningful benefit? A frenulum should not be divided simply because it looks prominent, because it has been given a particular label, or because of a theoretical concern about what it might cause years later. The child in front of us, their current function and their current symptoms should guide assessment and treatment. Why appearance alone is not enough Photographs of infant mouths can be compelling, especially when a parent is searching for an answer after difficult feeds. However, an image cannot show how a baby coordinates sucking, swallowing and breathing, how comfortable the feeding parent is, or whether milk transfer is effective. A function-focused assessment considers the baby as a whole. It includes a careful feeding history, growth and wellbeing, the parent’s goals, and direct observation of a feed where possible. In breastfeeding, this may involve considering attachment, comfort, audible swallowing and breast drainage. In bottle feeding, it may involve observing coordination, seal, pacing, stress cues and the baby’s comfort. This approach also makes room for conservative support. Sometimes a change in positioning, attachment, feeding pace, pump flange fit, milk supply support or a period of follow-up makes a meaningful difference. Sometimes concerns persist despite skilled input and a restrictive lingual frenulum appears to be contributing. Neither pathway represents failure. Validated assessment tools can support structured observation, but they should not be used as a stand-alone decision-maker. The Academy of Breastfeeding Medicine emphasises that no published tool should be the sole basis for deciding whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). Clinical reasoning remains essential. What does the evidence say about frenulotomy? For infants with tongue-tie and breastfeeding difficulties, randomised trials reviewed by O’Shea and colleagues found that frenulotomy may reduce maternal nipple pain in the short term. However, evidence for longer-term breastfeeding outcomes remains less certain, partly because studies are small and use different definitions, measures and follow-up periods (O’Shea et al., 2017). This is an important balance to communicate. Some families report a noticeable change after frenulotomy, while others need ongoing feeding support, see a more gradual change, or find that the procedure does not address all their difficulties. A frenulotomy is therefore a considered option within a broader plan, rather than a guaranteed solution. Where a procedure is being considered, families should receive clear information about the reason for the recommendation, potential benefits and limitations, possible risks, alternatives and aftercare. Their informed preferences matter. Some families choose to continue with conservative management or to seek review later; others feel that a procedure is the right next step after assessment and support. Both deserve respectful, non-judgemental care. There is insufficient evidence to recommend surgical treatment of an upper lip frenulum for breastfeeding concerns. It is also worth being cautious about claims that oral ties reliably explain later speech, sleep, dental, posture or developmental concerns. These issues require their own appropriate assessment and should not be predicted from infant oral anatomy alone. When to seek further support A further assessment may be helpful when feeding remains painful, stressful or inefficient despite appropriate support, when there are concerns about growth or hydration, or when parents feel something has not been fully understood. Urgent medical review is appropriate if a baby is very sleepy and difficult to rouse for feeds, has markedly fewer wet nappies, shows signs of dehydration, is unwell, or there are concerns about weight gain. For professionals, it can be helpful to document both positive and negative findings. A baby may have a visible frenulum but good tongue function, comfortable feeding and appropriate growth. That information is as clinically meaningful as identifying restriction. It protects families from unnecessary intervention and keeps the focus on their actual needs. D-Restricted Ltd® approaches infant feeding and tongue-tie care through this function-focused lens: listening carefully to each family, assessing feeding as well as anatomy, and supporting collaborative decisions about next steps. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. American Academy of Pediatrics (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 154(2), e2024067605. Messner, A.H., Walsh, J., Rosenfeld, R.M., Schwartz, S.R., Ishman, S.L., Baldassari, C., Brietzke, S.E., Darrow, D.H., Goldstein, N.A., Levi, J., Meyer, A.K., Parikh, S.R., Simons, J.P., Yellon, R.F. and Mitchell, R.B. (2020) ‘Clinical consensus statement: Ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. When feeding feels difficult, the most helpful next step is rarely a judgement based on one visible feature. It is skilled, compassionate support that considers the baby, the feeding parent and the feeding relationship together.

A small white, cream or yellow area beneath a baby’s tongue can look worrying, particularly when feeding has already felt difficult. Questions about tongue-tie wound healing in a baby are very common after a frenulotomy. Knowing what may be part of normal healing, and what needs prompt clinical review, can help families feel more settled while keeping the focus on their baby’s comfort, feeding and wellbeing. A frenulotomy creates a small wound where the lingual frenulum was released. Healing is usually quick, but every baby and feeding journey is individual. The appearance of the wound alone cannot tell us whether feeding will improve, whether a tie was the only factor affecting feeding, or whether further support is needed. What does a healing tongue-tie wound look like? In the first days after a frenulotomy, the area may look red or pink. As the wound heals, it is common for a white, cream, yellow-white, or even yellow, orange, or bright fluorescent-looking patch to develop. If your baby has some degree of jaundice, these brighter yellow or orange colours may be more noticeable. This is a normal finding and is not, on its own, a cause for concern. The healing wound is normally covered by a soft, moist layer of granulation tissue. Granulation tissue is healthy new healing tissue made up of tiny new blood vessels, connective tissue, and cells that repair the wound. In the mouth, it is often covered by a thin layer of fibrin, giving it a white, cream, or yellow appearance. This is a normal part of wound healing and should not be mistaken for pus. Colour alone is not a reliable sign of infection. Infection after a frenulotomy is uncommon. True pus is different from the normal healing layer and is usually accompanied by signs that a baby is unwell, such as fever, poor feeding, increasing irritability, unusual sleepiness, or a baby who appears generally unwell. If you are concerned about your baby's recovery or wellbeing, seek medical advice. Over the following days, the area often becomes smaller and less noticeable. The time taken varies. A clinician who has seen your baby and knows their history is best placed to advise on what is expected for them, particularly if there were feeding concerns before the procedure. Occasionally, a small spot of re-bleeding may occur later at home, particularly in the first 24–48 hours. This is usually minor and settles with the advice provided by your practitioner. Prolonged or heavy bleeding is uncommon. If you have concerns about bleeding, refer to the Association of Tongue-tie Practitioners' Prolonged Bleeding Management Guideline: https://www.tongue-tie.org.uk/bleeding-guidelines. There is limited high-quality research describing the day-by-day appearance of infant frenulotomy wounds. Much of the practical advice families receive is therefore based on clinical experience alongside general principles of wound healing. For infants under the care of D-Restricted Ltd, a wound healing timeline and variance gallery are available to view in your support portal. As every baby heals at a slightly different rate, the timeline is intended to illustrate the typical pattern of healing rather than represent a fixed day-by-day schedule (www.tongue-tie.info/parents-area). Feeding and behaviour in the early days Some babies feed straight away after a frenulotomy; others need time to adjust. A baby may be temporarily unsettled, feed more frequently, or seem to be working out a different way of using their tongue. This does not necessarily mean there is a problem with the wound. An immediate improvement in feeding is possible, but it is not the most common outcome. Many babies need time to adapt to their increased tongue movement and may initially seem less coordinated or tire more quickly during feeds before feeding becomes easier and more efficient. Early fluctuations in feeding are therefore common and do not necessarily indicate that the procedure has been unsuccessful. It is also important to recognise that wound healing and feeding outcomes are not the same thing. While the frenulotomy wound usually follows a predictable healing pattern, the time it takes for a baby to achieve comfortable, efficient feeding varies considerably. Feeding is influenced by many factors, including a baby's age and developmental stage, their tongue strength, tone and pre-existing feeding skills, as well as any compensatory muscle patterns or body tension that developed before the restriction was released. Birth factors, positioning, attachment, milk supply or flow, and other individual circumstances may also influence recovery. Feeding is a relationship involving infant oral function, positioning, attachment, milk transfer, breast or bottle dynamics, parental comfort and a baby's wider health. If feeding remains painful, stressful or inefficient, skilled feeding support can be just as important as monitoring the wound itself. For breastfeeding families, support may include observing a whole feed and considering comfort, audible swallowing, milk transfer and the baby's growth pattern. For bottle-feeding families, it may include assessing feeding pace, teat flow, positioning, coordination and signs of fatigue. Families who combination feed or express milk deserve the same thoughtful, individualised, non-judgemental support. Evidence suggests frenulotomy 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; Francis et al., 2015). This is why careful assessment, realistic discussion and continuity of care matter. Why aftercare should not centre on the wound alone Families may encounter strong and conflicting messages online about how a tongue-tie wound should look and what should be done to it. This can create unnecessary anxiety, especially when parents are tired and trying to establish feeding. After a frenulotomy, it is important to distinguish between wound manipulation and activities that support tongue function. Deliberately lifting, stretching, rubbing, reopening, or otherwise disturbing the healing wound is not advised, as this may cause discomfort, disrupt the normal healing process, or increase the risk of bleeding. The wound does not need to be physically manipulated in order to heal effectively. This is different from supporting your baby’s oral function following the procedure. Some babies may benefit from appropriately guided, individualised support to help them adapt to their increased tongue movement and develop more efficient feeding skills. This may include activities that support tongue movement, coordination, strength, and relaxation of surrounding muscular tension. These are functional activities, not wound exercises, and should not involve pulling on, stretching, or interfering with the healing site. Any post-procedure support should be tailored to the individual baby and delivered in line with appropriate clinical guidance. The Association of Tongue-tie Practitioners (ATP) position statements on wound management and post-procedure care can be found here: https://www.tongue-tie.org.uk/position-statements. Follow-up is an opportunity to understand function A follow-up conversation (https://www.tongue-tie.info/post/tongue-tie-reassessment-after-release-explained) or appointment should make room for more than checking whether the wound has healed. It can explore what feeding was like before the procedure, what has changed, what remains difficult and what support would feel most useful now. For healthcare professionals, this means resisting the temptation to interpret anatomy in isolation. A visible frenulum provides information; it does not, by itself, define feeding function or determine the right management pathway. A functional assessment, differential diagnosis and careful feeding history remain essential before and after a frenulotomy. For families, it can be reassuring to know that needing further feeding support does not mean anyone has failed or that the procedure was necessarily inappropriate. Some babies need time, some need changes to feeding support, and some feeding difficulties have causes unrelated to a lingual frenulum. Practical care while your baby heals Keep the focus on ordinary, responsive care. Offer feeds in line with your baby’s cues and any feeding plan agreed with your clinician. Monitor their usual signs of adequate intake, such as feeding behaviour, wet nappies and weight checks where these have been advised. It can be helpful to take a photograph only if your treating clinician has asked you to monitor a particular change. Repeatedly checking the mouth, comparing photographs online or trying to interpret wound colour without clinical context can heighten worry without providing useful answers. If you have been given written aftercare by the clinician who performed the frenulotomy, that advice should take priority because it reflects your baby’s assessment and the service’s follow-up arrangements. Ask for clarification if any part of it feels unclear. A healing wound is only one small part of the picture. The more meaningful questions are whether your baby is well, whether feeding feels manageable and whether you feel listened to. Compassionate follow-up can hold all three together. 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. National Institute for Health and Care Excellence (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. Thomas, J., Bunik, M., Holmes, A., et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 154(2), e2024067605.

Frequently Asked Questions We know that there are many adults who also struggle with a restrictive tongue-tie. Usually by adulthood though they have 'learnt' to function their tongue in a compensatory way, many of these adults are absolutely fine and unaware they even have a restriction (or that it is the root cause of any potential symptoms they may have). We know that there can be potential issues later on but these are poorly researched, and we don't have a crystal ball to say that it will or wont affect your infant years down the line. But in essence speech, oral cleanliness, tension aches/ migraines, breathing/sleeping/snoring and dental implications have links to a restrictive frenulum but nothing is 100% definitive as yet but research is being done all of the time. Generally, especially in the early days a tongue-tied infant can also gain weight. Many people seem to understand that they can loose weight but if they are an inefficient feeder, they may have long or frequent breastfeeds. Or, if bottle fed; either down a bottle too quickly (so you think they're ravenous but its more that they are not in control of the flow and you over feed them) or feeds are so long they end up taking in more calories than what they need. They tend to be branded as 'lazy', 'snackers' or 'grazing'. Some even believe that it will 'snap' of its own accord. Can you imagine how that may feel in an uncontrolled environment? And, even then it may/may not 'tear' all of the restrictive element. Infection risk, bleeding management and potential pain come to mind as things to consider too, especially if older. A restrictive frenulum affects tongue motility and efficacy. The tongue-tie itself is not particular how you feed to 'decide' if it will affect your chosen feeding method or not! This one really baffles me! Using ambiguous terms not only confuses parents or gives the wrong 'impression', they are also terms that just do not give us much information. I see many parents who are told "it wont cause any issue because its a mild one" and yet the infant is clearly struggling. Similarly, the opposite is true-parents being told its severe. Or ones 'at the front' need doing-yet they have a long stretchy frenulum and are feeding fine. It really is not about what it looks like-its all about what it can or can not do which is why an assessment with an experienced practitioner is important. And again, not all healthcare professionals say the same thing! And thats really annoying. Training to diagnose and assess for a tongue-tie restriction is NOT part of any healthcare professionals routine medical or otherwise training. It is a separate specialist course. Sure, many midwives, health visitors, paediatricians and doctors all have their opinion on it-but unless they have been trained in it, then it is just that. An opinion. There is a wealth of research to support tongue function which is continuously growing. Ask your healthcare professional for their 'opinion' by all means, many are usually correct anyway as they have a wealth of experience, but unfortunately there will always be someone whose 'opinion' is mistaken for fact. Everyone seems to have a tongue-tie these days! Having a release is just a new-age fad! Yes, I have been told this too. As if someone would do a cut for no reason? unethical. Its not new at all-there is reference to it in the bible, Medieval texts>> In the Victorian era we know that midwives would grow their little fingernail and do a division as the baby is being born. So no, not new. We did progress with medical advances in hygiene and in some cases formula/bottle companies would pay or sponsor healthcare providers to promote their formula milks over breastfeeding (check out 'the nestle boycott') so a division became less known about. But it is not new. Certainly past generations would understand it with differing terminology, such as a 'short tongue.' Will having a tongue-tie divided hurt my baby? or cause discomfort? NICE (2005) Division of ankyloglossia (tongue-tie) for breastfeeding is a recognised and long established document discussing the benefits and risks of a division. This document is freely available via an internet search should you wish to check it out. The document refers to a study that concludes that 1 in 8 infants will sleep through the whole procedure. The problem is that although we believe this is the case-they can't tell us. The remaining 7/8 would cry - but they are in a strange environment with an unknown adult doing a procedure whilst being gently restrained so it is also possible that they are just unsure/discombobulated/in shock because it is so super-duper quick they haven't really had chance to get their bearings yet. However, some babies do become very fussy at feeding afterwards, which I can understand, but again short lived and unlikely pain related. If I choose for my baby NOT to have a release, does this mean they will have a speech impediment? Nope, not necessarily. Researchers are looking into this. We know that there is a potential that it may, this is true, but it is not conclusive. The current studies that we have though look at children with a short anterior (to the tip of the tongue and attached to the lower gum ridge) and conclude its possible-but it doesn't look at all of the other types of restriction, and there are many other reasons a child may have speech issues separate to a tongue-tie restriction. Speech articulation is also linked to a high palate (roof of the mouth) which happens in embryology particularly if theres a tongue-tie restriction. Is having a tongue-tie restriction hereditary? Again, there is no definitive research on this one but it is believed to have an hereditary element to it, but no one really knows. It is also marginally more common in males too-but again we do not know why I can see a vertical 'stringy' bit under my baby's tongue. Does this mean my baby has a tongue-tie restriction? No. Everyone has a lingual frenulum. That is oral anatomy. It is only considered restrictive in infancy if there are feeding implications hindering efficacy. This, coupled with a tongue function test assessing the parent-baby dyad holistically is used to suggest if there is a restriction or not. Here is a video of an assessment conducted by my colleague Sarah Oakley: Do you also provide division of lip-ties? No, a division of a lip-tie in the UK can only be performed by specialist oral surgeons and dentists. It is not something that is considered necessary in infancy as there is no robust evidence to suggest it affects infant feeding-but it can later on in life but more so dentally. please refer to ATP position statement on Lip-ties and also my blog "What is a lip-tie?" https://www.tongue-tie.org.uk/position-statements https://www.tongue-tie.info/post/what-is-a-lip-tie-does-it-need-treatment What are the risks involved with a surgical release? Please refer to the page on this website for more detailed information (Tongue-tie tab above). https://www.tongue-tie.info/tongue-tie My baby was diagnosed with a tongue-tie restriction, we didnt opt for a release-and they were fine I would question who and how the diagnosis was made. If your infant has a true tongue-tie restriction, they will have been symptomatic. If they were/are 'fine' and have no issues-whilst thats great-they were not tongue-tie restricted. © Diana Warren IBCLC, RGN D-Restricted Ltd

INTRODUCTION: Both historically, and more recently, it has been reported that there has been a rapid increase in the prevalence, diagnosis and treatment of a restrictive tongue-tie . A restrictive tongue-tie, or ankyloglossia has been identified by NICE (2005) as “A congenital anomaly characterised by an abnormally short lingual frenulum; the tip of the tongue cannot be protruded beyond the lower incisor teeth.  It varies in degree, from a mild form from which the tongue is bound by only a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth.  Breastfeeding difficulties may arise as a result of the inability to suck effectively, causing sore nipples and poor infant weight gain .” More recently, Mills et al (2019) suggest that a frenulum may be classified as fascia within the midline fold beneath the mucosa, fusing connective tissue to the ventral surface of the tongue. The NICE (2005) definition further limits potential problems to those who exclusively breastfeed. However, a restrictive frenulum does not have a feeding-method preference! It can affect all methods of feeding, inclusive of bottle feeding, the introduction of solid foods, dentition, oral hygiene and potentially speech complications such as pronunciation of certain sounds too.  The National Health Service (NHS) provide an informative parent guidance leaflet for the care and management of a tongue-tie restriction which acknowledges bottle feeding complications (NHS 2023). What does not seem to be considered are the cases where breastfeeding is inefficient and so artificial feeding is commenced as a last resort where the root cause has not been identified, and so is an alternative method of feeding only.  Maternal feeding choices are therefore limiting and removes their right to feed their infant however they so wish.  This may lead to an increase in feelings of guilt, pressure a nd an impact on maternal mental health. The key is tongue efficiency rather than appearance alone, alongside skilled infant feeding professional support.  This would further ensure parental support protecting infant feeding, maternal mental health and prevent any potential risk of over/mis-diagnosis. CLASSIFICATION/DIAGNOSIS: There are a number of classification and grading assessments used globally to identify a restricted tongue ‘type’. Generally, this is done visually in accordance to the physical sight of attachment of the lingual frenulum on the underside of the tongue, and the floor of the mouth, its thickness and elasticity.  Hazelbaker (2017) acknowledges that there are 7 areas of tongue function to be considered, and that although appearance is taken into account, a visible frenulum without functional restriction is deemed as normal anatomy.  Harhan et al (2014) supports this notion stating that an anatomical finding, which is not correlated with breastfeeding difficulties, is not a restrictive frenulum.  Todd & Hogan (2015) identify 4 ‘types’ of ankyloglossia based on appearance, categorised by numbers. Their reclassification of the Coryllos (2004) tool uses a percentage metaphor based on how far forward the lingual frenulum presented, measuring from base of the genioglossus, to the tip of the tongue (<25%=posterior; 25-50%; 50-75%; 75-100%=anterior).  Baeza et al (2017) indicate that correct assessment of a tongue-tie  is essential in order to help the infant thrive, protection from breastfeeding cessation, and other feeding issues too. Many healthcare professionals do use an assessment tool to assist them in their suspicion to help confirm a diagnosis or, just as importantly, rule one out. Assessment tools are used in conjunction with the practitioner’s judgement, based on maternal and infant symptoms, feeding behaviours, supply, medical conditions, and medications as part of an overall holistic assessment of the feeding dyad.  Tools are not diagnostic as a stand-alone feature; it is there to support holistic assessment of the feeding dyad. Hazelbaker A (2017) Assessment tool for lingual frenulum function Kotlow L Scale (2004) Bristol Tongue Assessment Tool (BTAT) Tongue Tie and Breastded Babies (TABBY) Todd & Hogan (2015) Visually categorised over 5 different aspects, and given a maximum total score of 10. Additional 7 areas for function assessment with a maximum score of 14. Classified as a ‘type’. There are 5 main ‘types’ based on where the attachment of the tip of the frenulum is placed in the mouth. 4 visual aspects that categorise appearance to give a score. Originally based on ATLFF scoring tool. 12 different images for the assessor to choose and categorise. Based on Coryllos 2004 scale. Uses a 4 point scale based on the attachment site of the frenulum to the tongue. (Figure 1.0 to demonstrate some of the assessment tools available) There are many signs and symptoms of a tongue-tie in an infant, but they do not necessarily all have to b e present  and the key is to identify that the root cause of the restriction.  This is why an infant feeding specialist, with experience and relevant qualifications is best placed to ensure the symptoms are function related, and not accounted to another cause(s), i.e. oral thrush or positional in origin, as these problems will persist even once any potential restriction is removed. Maternal nipple pain/nipple trauma; usually caused by the inability to maintain and sustain a wide gape and latch and is common in the infants who struggle with extension and elevation of the tongue. Clicking; a noise made when the tongue slides back and loses suction (snapback), these infants tend to swallow lots of air, gulping, vomits/posseting after feeds, colic and abdominal discomfort. Weight: is affected as the tongue is inefficient, it has an un-coordinated rhythm and suck: swallow ratio which results in tiring/exhaustion of the infant quickly, resulting in short but frequent feeds.  Weight may falter, but may also increase due to the frequency of feeding times, potential induced oversupply and/or fast flow. Flow control: of the milk, can be gulping, coughing, breaking the seal, which can also consequently lead to symptoms of reflux. Dribbling-the inability to create a vacuum seal using a combination of both the palatoglossal muscle and lip tone/closure (Baviaktte et al 2012).   High Palate:  Furthermore, Hazelbaker (2010) also recognises that the palate begins its development during embryonic phase and completes by week 12 where the tongue separates itself to form the palate structure.  In the case of a tongue restriction the palate can form a higher arch (usually remaining intact) in response to the lack of support to form a symmetrical arch from the tongue body.  This results in common s ymptoms such as reflux, gulping, hiccoughs secondary to aerophagia, and can also affect oral hygiene. PREVALENCE: Fernando (1998) acknowledges that being tongue-tied is not a new disorder or diagnos is and Hazelbaker (2010) in her book details evidence of historical records dating back to 1700s in relation to breastfeeding and how the infant’s ability improved once released.  In 1918, Koplik suggested a heart-shaped tongue as a ‘type’ requiring excising due to inefficiency to breastfeeding.  From 1697 until the 1900’s, mi dwives would grow their little fingernail, which was sharpened so they could sweep under the tongue with the aim to excise the frenulum immediately and then place baby to the breast.  After the 1850’s, surgeons and midwives preferred a conservative approach to ankyloglossia due to advances in hygiene, and cultural choice so frenulotomy incidence reduced (Baxter 2018) .  Bottle feeding using cow’s-milk based formula latterly became popular (through aggressive marketing strategies)-and although we know that tongue function is prevalent in the bottle-fed infant too; the mechanics of tongue motility differs in bottle feeding.  It also took away maternal problems a tongue restriction may cause (i.e. pain, reduction in breast milk supply, increased frequency) masking the signs that only a mother could advocate for her infant.  Consequently, formula companies took the opportunity to influence decisions through marketing, resulting in generations of malnourishment with grossly misinformed parents/caregivers believing a formula feed was an advanced innovation that superseded breast milk.  Unfortunately, even today, many mothers report being told “If you can’t breastfeed there’s always a bottle” both from well-meaning family members and healthcare professionals alike.  In 1985, the first lactation consultants trained through International Board of Lactation Consultant Examiners (IBLCE) and started researching the impact and consequences of not breastfeeding.  In 2005 NICE published guidance deeming it a safe procedure with minimal risks.  More recently the procedure became regulated, and it is now a requirement that tongue-tie practitioners in England are registered and regulated by Car e Quality Commission (CQC, 2019) following clarification in UK law. DIAGNOSIS: There are a few ways that parents/caregivers of a tongue-tie restricted infant may receive a diagnosis.  Although unfortunately, many are based on assumption or visual appearance, lack of knowledge, poor experiences and opinions.  This is evident in the way parents/caregivers present to professionals who are often told a yes or no definitive answer to the question “Is my infant tongue tied?.”  Parents/caregivers look to the healthcare professionals expecting them to provide evidence-based responses, yet this is not happening because the healthcare professionals are not receiving the training or education as it is not part of national standard healthcare training, and individual access to specialist trai ning requires funding.  This provides a further challenge to new parents/caregivers accessing a diagnosis, unaware of who may support them. This may include: Hospital infant feeding team, Hospital midwife at point of delivery, Community midwife, maternity assistants, Peer support workers-mother-supporters, Breastfeeding/chest feeding charities, Healthcare professional performing newborn examination (NIPE), Health Visitor, Word of mouth/family/friends/social media/search engines, GP review at 6-8 weeks post delivery, Hospital and community-based infant feeding teams, Paediatrician/medics. A more appropriate response may include “I am not trained to assess for a tongue restriction, but I could refer you to our local infant feeding specialist/here is the ATP information website details so this can be further explored”.  The Association of Tongue Tie Practitioners (ATP) lists both NHS and private practitioners covering the United Kingdom (UK) in accordance with geographical location. A healthcare professional is best placed to signpost to the professional website as it allows parents the option to see who is local to them allowing for informed choice and autonomy ( www.tongue-tie.org.uk/find-a-practitioner ). PROVISION: Across the UK, parents/caregivers have a limiting choice with NHS services who, have different criteria and waiting lists, set by local Clinical Commissioning Groups (CCGs) or Integrated Care Systems (ICSs).  These include the method of feeding, age or weight criteria.  Some areas do accept referrals from breastfeeding supporters and health care professionals or to a local infant feeding team who may assess and then refer to an NHS service should a frenulotomy be suspected to be beneficial for their assessment.   Parents/caregivers may also self-refer into private services, and the ATP house a directory of regulated providers, but this option is often not always verbalised to them. To list a service with ATP, tongue-tie practitioners must prove their competence and regulation as required in law.   SURGICAL TREATMENT: Scissor Divide Griffiths (2004) describes a scissor division as lifting the tongue with the forefinger and holds the infants chin with a thumb.  Using sterile blunt-ended scissors, (without anaesthetic) cuts through the membrane to release the restriction. Considerations of this method include: Quick, Minimal risk, No medications or anaesthetic involved, Instant feeding/sucking post division to release endorphins and oxytocin (natures natural analgesics), No sutures, Low cost in comparison to alternative options, Readily accessible, UK based practitioners are also healthcare professionals who are trained in infant feeding which allows for a plethora of infant feeding and suck issues to be addressed simultaneously (or in advance of division). Laser Kotlow (2004) uses a laser, also without anaesthetic-lifting the tongue to excise with one exposure to laser. Considerations of this method include: Minimal bleeding, Minimal infection, Takes longer to preform/prepare in comparison to scissor, Removal of tissue rather than incision into it, Performed by surgeons, few of whom are also trained in infant feeding, and so rely on those specialising in that field, Cost implications. Diathermy and electrocautery Kummner (2005) describes this method utilising a device that passes an electronic current through an electrode which is a metal “needle” heated by the electrical current, that generates heat to cauterise the frenulum and any surrounding blood vessels. Local anaesthetic is administered, Advocates for Disruptive Wound Management (DWM), Uncommon practice in the UK. ASSOCIATED RISKS:                     NICE (2005) acknowledges that division of a restrictive lingual frenulum is a relatively safe procedure with rare incidence of known risks and lists these complications as: bleeding, infection, ulcers, pain, damage to tongue and surrounding tissue and reformation. Bleeding Bleeding is a complication of any wound inducing procedure.  A frenulotomy procedure is not liken ed to a bl ood loss but can be small vessel or capillary related. In the majority of cases only around half a teaspoon of blood loss is expected, it is not an arterial loss, and this usually subsides immediately after the procedure through feeding, which not only provides pressure to the area to stem the bleeding, but also comfort to the infant through stimulating the sucking reflex inducing an oxytocin release. The estimated risk of continued bleeding is currently suggested to be 1:400, following pressure and feeding management, the risk further reduces to 1:7,000 for those requiring medicated buccal treatment (ATP 2017).  A further audit by ATP (2018) suggested the at the required need for medical intervention (sutures or cautery) is 1:76,764, suggesting that prolonged pressure controlling the bleeding stemmed the oozing en-route to hospital.  There is a risk of bleeding being caused by inadvertent injury to small vessels or other oral structures too, which are an anatomical anom aly and u npredictable.  These cases are believed to be few but there are no studies to suggest its incidence (and it is possible incidence is under-reported). However, the management and control of any bleed is the same regardless of the type/cause. Infection It is believed that infection risk to the division site is estimated at 1:12,015 (ATP Complications Audit 2022).  All surgical wounds are subject to risk of infection intro duction or cross contamination, but by ensuring the practitioner uses an aseptic te chnique, sterile scissors and gauze, handwashing (and antibodies found naturally occurring in breast milk) all contribute to lowering its risk further. Ulcers Following a scissor divide, the wound heals through primary intention, and visually looks like a mouth ulcer.  This is part of what is considered the ‘normal’ wound healing process and gradually gets smaller before finally dissolving and dispersing into the mucosa where nothing further can be visualised, and on average takes 7-10 days. Pain It is not fully known i f the procedure itself is painful.  However, as the infant is temporarily restrained and in a potentially unfamiliar environment, the infant may become unsettled after the procedure which may discombobulate the infant, who is then released, comforted and offered a feed.  We also know that 8% infants do sleep through the whole proce dure (NICE 2005). In young infants there is usually no need for local anaesthetic and may be seen as counter productive because numbing an area results in not being able to feel a feeding -vacuum which may prolong the bleeding timeframe.  Numbing gels are believed to be ineffective as swallowed by i nfants rather than allowing absorption time, rendering ineffective use-but it is also unknown how a gel may react against within an open wound. Damage to tongue and surrounding tissue A rare complication is the inadvertent injury from the scissors, controlled by the practitioner, to the ventral tongue surface or surrounding oral structures, which is inclusive of the salivary glands or other fragile oral structures.  The scissors do not have the strength to cut through the genioglossus muscle itself, but ma y damage the lip, tongue, submandibular glands or other oral structures.  Treatment would be managing blood loss, but it is not expected to impact long-term function, and this risk is further minimalised by momentary restraint of the infant. Reformation Reformation may include a few possibilities.  It does not technically “regrow”, but it may present restriction through residual frenula protrusion as the tongue body comes forward.  Or through wound scarring which would be restrictive through fibrous and taut formed tissue. Hazelbaker (2014) discusses how the frenulum is very much likened to ligament tissue, rather than membrane, so it would remain relative within the mouth as the infant grows. In these cases, a second scissor divide may be considered but more than that may be viewed as counter-productive (scar overlapping further scar) so in these cases referral to a specialist surgeon or dentist may be suggested.  Reformation is thought to affect 1-4% of scissor divides (NHS 2014).   All infants vary on their behaviour/response following the division, and is influenced by many factors including: availability of maternal milk supply, timing of the previous feed, age/alertness of the baby, medical conditions, environmental factors, tiredness, hunger level. EFFICACY: There are a number of studies that have b een completed, both supporting and dismissing a surgical frenula release.  Unfortunately, very few of these are reliable or valid. The general notion is that a surgical release does help with infant feeding complications in the reduction of maternal breastfeeding pain in particular, but further research is needed (Hazelbaker 2010). SUPPORT & AFTERCARE: The chosen clinician providing the surgical procedure (frenulotomy) remains the accountable practitioner, and so parents are to be encouraged to access support through their means.  Healthcare professionals are responsible for their actions and is linked closely to accountability (Elcock 2018). Adversely, this may not always be possible.  For example, an ENT surgeon offering tongue-tie division may not also be trained in breastfeeding support, particularly when considering them as a dyad rather than the infant being the sole patient (as one).   A healthcare professional in this position may instead consider referring to a provider that could, or ensure that the parent/caregiver had access to the skilled support needed.  Similarly a parent/caregiver may wish to seek a second opinion, or, should the appointment be for a second divide-the infant may be too old to suit the original provider’s age criteria.  Local support largely varies across the UK, fluctuating on access to breastfeeding support where a mother may choose to seek support with attachment and positioning.  Although valuable, qualification level and experience can be limited, with many being volunteers with a desire to help rather than professional support, where post tongue-tie division is not within their remit. The matter is usually complex, with training in breastfeeding usually being a basic, minimum standard and not inclusive to bottle fed infants despite there being a robust infant feeding qualification which is accredited and board certified (IBCLC) which is also globally recognised available (Oakley 2021). WOUND CARE: Wound stretches and disruptive wound management are commonplace internationally, and very few areas of the UK.  Some versions involve stretching through the use of finger pressure against the frenulotomy wound to tear the wound edges with the aim to re-open it to its original ‘diamond’ shape.  Some recommend a sweeping motion under the tongue to keep the wound open . The ATP (2022) have categorised levels of wound care instructions, level 1-4 which progress in intervention. Unfortunately robust evidence suggesting efficacy (or not) of this practice is sparse.  However, when studying the wound healing process, a division would create an acute wound which predominantly uses secondary intention healing (unless sutures are used). Brown (2015) describes the 4 phases of normal wound healing Phase (1) Inflammation: the blood clot/scab formation, Phase (2) Destruction: the white cells clean the wound and slough production, Phase (3) Proliferation: new tissue generation-encouraging wound healing from the base of the wound to the surface, Phase (4) Maturation: wound edges coming together to form wound closure. Due to this an introduction of stretches or disruptive wound management will cause delay to phases 2 and 3 which will result in the formation of over-granulation.  It is defined as an excess of granulation tissue that fills the wound bed to a greater extent than what is required due to the delay in wound healing phases (Jaeger et al 2016). Ghaheri (2015) insists that the prevention of wound reattachment can only be achieved by actively stretching the wound. Despite this, UNICEF UK (2019) make a clear statement that “there is no need for any form of wound management-the baby just needs to be fed”. Ghaheri is not alone in his assumptions. O’Callaghan et al (2013) suggests that fewer revisions are needed when the tongue is elevated to stretch the wound.  Currently there is no evidence to advocate the need for wound massage or stretching (ATP 2022). Kendall-Tackett et al (2017) interviewed tongue-tie specialist professionals who disagree that wound stretches/disruptive wound management should be encouraged and that there are additional risks to doing them such as causing an oral aversion, or pain, due to the repeated uncomfortable/painful digital intrusion.  Other risks include bleeding and the introduction of infection.  There is of course a very notable difference between wound stretches and tongue function sucking exercises, and commonly the two are confused to mean the same practice.  Tongue suckling exercises do not touch the wound site at all and aim to assist with feeding through tongue strengthening techniques, such as those described by Watson-Genna (2013).  Whereas wound stretches an d disruptive wound management do touch an open healing wound.  Data suggests that wound stretches and disruptive wound management intervention make very little difference (NHS 2014). MIS-DIAGNOSIS AND OVER-DIAGNOSIS: A faux tie is when the infant-mother dyad are presenting with stereotypical symptoms of a restrictive tongue-tie, and yet on assessment the tongue function is usually a borderline impa irment and visually resembles that of a submucosal frenulum.  A submucosal restriction (or type 4) is not usually visually obvious and may present to palpation to the wound bed or to touch.  Hazelbaker (2014) believes this is not frenulum, but it is the septum of the genioglossus muscle and that there are knowledge gaps around tongue anatomy and structure.  The feeding symptoms can therefore be attributed to other causes (structural restrictions that pull the tongue back into the throat, such as birth trauma –caesarean section or instrumental delivery causing muscular tension by cranial structures through exerted forces as an example).  It highlights the importance of using a robust tool by a qualified and experienced practitioner and using a conservative approach to surgical division.  As there is not a universally agreed definition of ‘posterior’ or ‘sub-mucosal’ frenulum it is the authors opinion that this is where much confusion is attributed to, but reinforces how skilled infant feeding support as a specialism is paramount to the overall success and outcomes of a frenulotomy procedure.                               CONCLUSION: In conclusion, there is still much learning to be conducted around the frenulum as an anatomical structure, why the restrictive anomaly occurs in some infants, and not all (or none) and a universal system for screening assessment, treatment and expert infant feeding support.  Similarly the NICE guidance of 2005 is clearly now quite dated in its guidance, and would benefit from being updated as new research is continually being formulat ed. Currently, there are healthcare professionals diagnosing and misdiagnosing ankyloglossia where further training required, rather than a holistic infant feeding assessment using evidence based robust assessment tools and skills by a highly skilled, trained and experienced practitioner.  They instead are using confusing and ambiguous terminology looking at appearance o f the frenulum only and not addressing tongue function collectively.  Studies currently suggest that prevalence is on the increase both internationally and in the United Kingdom (UK), but there is nothing to suggest that this is an increase in occurrence, merely an increase in diagnosis.  In turn, this may be due to an increase in awareness, and not an increased prevalence. This is why this article aimed to highlight the importance of skilled infant feeding diagnosis and care, to prevent incorrect diagnosis and timely efficient support for the parent-infant dyad.  REFERENCE LIST Association of Tongue tie Practitioners (ATP) (2017) “Care after tongue-tie division (frenulotomy)” Association of Tongue-Tie Practitioners www.tongue-tie.org.uk/information . Association of Tongue tie Practitioners (ATP) (2017) “Guideline for the management of bleeding post frenulotomy” Revised edition Association of Tongue Tie Practitioners  UK www.tongue-tie.org.uk/bleeding-guidelines . Association of Tongue tie Practitioners (ATP) (2018) “Results of ATP bleeding and scissor survey”  Association of Tongue Tie Practitioners , UK www.tongue-tie.org.uk/audit . Association of Tongue tie Practitioners (ATP) (2022) “Complications survey for 2022” www.tongue-tie.org.uk/atp-audits . Association of Tongue tie Practitioners (ATP)  (2022) “Disruptive wound management-Position statement” https://www.tongue-tie.org.uk/atp-position-statements .  Baeza C, Watson-Genna C, Murphy J & Hazelbaker A (2017) “Assessment and classification of tongue tie” Clinical Lactation  8(3) p93-98. Ba vikatte G, Sit PL, Hassoon A (2012) “Management of drooling of saliva” British Journal of Medical Practitioners  5(1):a507. Baxter R (2018) Tongue Tied-How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding and More 1st Edition, Alabama Tongue-Tie Center, USA. Brown A (2015) “Wound Management 1: Phases of the wound healing process” Nursing Times  111(46) p12-13. Care Quality Commission (CQC) (2019) “Briefing for providers: Registration requirements for tongue tie procedures” https://www.cqc.org.uk/news/providers/briefing-providers-tongue-tie  (accessed 17/12/2023). Coryllos EV (2004) Assessment tool cited in: Brzecka D, Garbac M, Mical M, Zych B, Lewandowski B (2019) “Diagnosis, classification and management of ankyloglossia including its influence on breastfeeding” Developmental Period Medicine 23 (1) p79-85. Coryllos EV & Watson-Genna C (2009) “Breastfeeding and Tongue Tie” Journal of Human Lactation  25(1) p111-112. Elcock K (2018) Accountability and Professionalism  Chapter 7 in Delves-Yates (2018) Essentials of Nursing Practice 2nd Edition Sage Publications, UK. Fernando C (1998) “Tongue Tie from Confusion to Clarity: a Guide to the Diagnosis and Treatment of Ankyloglossia (Tongue Tie)” tandem Publications  Sydney, Australia. Ghareri D (2015) “The importance of active wound management following frenotomy” www.drghareri.com/blog/2015/6/21/the-importance-of-active-wound-management-following-frenotomy  (accessed 08/08/2019). Griffiths M (2004) “Do tongue ties affect breastfeeding?” Journal of Human Lactation 20 p409-414. Hahan A, Marom R, Mangel L & Botzer E (2014) “Prevalence of breastfeeding difficulties in newborns with a lingual frenulum-A prospective cohort series” Breastfeeding Medicine  9(9) p438-441. Hazelbaker A (2017) “Assessment tool for lingual frenulum function” https://www.lactspeak.com/alisonhazelbaker/presentation/using-the-hazelbaker-assessment-tool-for-lingual-frenulum-function  (accessed 15/11/2023). Hazelbaker A (2014) “The faux tie: when is a tongue-tie not a tongue-tie?” lecture accessed via GOLD Learning-Online Continuing Education www.goldlearning.com/lecture/69 . Hazelbaker Ak (2010) Tongue-Tie Morphogenesis, impact, assessment and treatment Aidan and Eva Press, Ohio USA. Jaeger M, Harats M, Kornhaber R, Aviv U, Zerach A & Haik J (2016) “Treatment of hyper granulation tissue in burn wounds with topical steroid dressings: a case series” Journal of International Case Reports  9 p241-245. Johnson PRV (2006) “Tongue-Tie Exploding the myths” Infant  2(3) p96-99. Kendall-Tackett K (2017) “The tongue tie controversy” Clinical Lactation  vol 8(3) p87-88 doi:10.1891/2158-0782.8.3.87. Koplik H (1918) the diseases of infancy and childhood: designed for the use of students and practitioners of medicine   Henry Kimpton Publishers  London p471.   Kotlow LA (2004) “Using the equilibrium. YAG laser to correct an abnormal lingual frenum attachment in newborns” The Journal of the Academy of Laser Dentistry  12 p22-23. Kummner A (2005) “Ankyloglossia. To clip or not to clip? That’s the question” The ASHA Leader  10(6-7) p30. Mills N, Pransky S, Geddes D, Mirjalili (2019) “ What is a tongue tie? Defining the anatomy of the insitu lingual frenulum” Clinical Anatomy  32 (6) p749-761 doi: 10.1002/ca.23343. National Health Service (NHS) (2023)”Tongue tie and Bottle Feeding”   https://www.nhs.uk/start-for-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-challenges/tongue-tie-and-bottle-feeding/  (accessed 27/01/2024) Crown copyright, UK. NHS (2014) “Frenulotomy-Post Procedure Advice Sheet-Maternity-Patient information leaflet” The Dudley Group NHS Foundation Trust  National Health Service, UK. NICE (2005) “Division of Ankyloglossia (tongue tie) for breastfeeding: Guidance” 1PG149 National Institute for Health and Clinical Excellence   https://www.nice.org.uk/guidance/ipg149 . Oakley S (2017) “The health visitor’s role in supporting families with tongue tied babies” Journal of Health Visiting  5(12) p594. Oakley S (2021) Why Tongue-Tie Matters Pinter & Martin Ltd, London UK. O’Callaghan C, Macary S, Clemente S (2013) “The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding” International Journal of Paediatric Otorhinolaryngology  77 p827-832. Todd D & Hogan M (2015) “Tongue Tie in the Newborn: Early diagnosis and division prevents poor breastfeeding outcomes” Breastfeeding Review  23(1) p11-16. UNICEF UK The Baby Friendly Initiative (2019) “Overcoming Breastfeeding Problems: Tongue-Tie” https://www.unicef.org.uk/babyfriendly/support-for-parents/tongue-tie/  (accessed 09/08/2019). Watson-Genna C (2013) Supporting Sucking Skills in Breastfeeding Infants 2nd Edition  Jones&Bartlett Learning, New York.

WHO CAN PROVIDE A TONGUE TIE RELEASE? This is a good question as there are so many opinions and variants of who-is-who, and criteria change depending on where you are in the world! Here I will try to help you find a reputable practitioner for those of you in England, UK. The first point of contact in those early days is usually your amazing midwife or health visitor. Healthcare professionals do vary in their range of skills, knowledge and experience though, but you can ask that they refer you to your local NHS infant feeding support team, as especially when considering a tongue-tie restriction and treatment, it is a very niche and complex specialist area. It would be wise to source a reputable Infant Feeding Specialist. This may be a member of your local NHS infant feeding team, or a Lactation Consultant (IBCLC) who, even if you are no longer/did not choose to breast/chest feed or provide human milk, still possess the gold standard qualification in infant feeding. Yes-they can support you however you choose to feed your babies including the use of formula milks. Many NHS services do not employ IBCLCs so you may consider sourcing one yourself privately. A list of Lactation consultants in Great Britain can be sourced at: www.lcgb.org/find-an-ibclc/ (A list of the different breastfeeding specialists and the qualification they hold can be found at the following link. Unfortunately, the title 'Lactation Consultant' is not protected, so please do check out the credentials of anyone that you choose to see. and this can be done by checking the professional register). www.lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/ 2). Your chosen Tongue-Tie Practitioner: I recommend that you take a few things into account. Their credentials, previous tongue tie experience, any recommendations from peers, family or professionals and VERY importantly-what aftercare support do they provide? How is it provided? Is that included in the cost or extra? (I would always expect to pay extra for extra support as training, time and experience cost the practitioner financially too. Thinking about it logically-all other areas of private care whether human healthcare or even veterinary you would pay at each additional appointment so. Bear in mind there location too. Do they offer a home visit or would you travel to their clinic? Should you need a follow up review-would you/could you travel that distance again? 3). Since 2019, ALL private practitioners in England must be registered with CQC, and in Scotland HIS. This is a legal requirement. You can search to check who is registered on their website www.cqc.org.uk, he/she may be listed by their professional name or in their company name. If you are unsure, ask the practitioner if they are registered! All registered professionals are inspected by CQC and their standard rating must be visible on their website. In the NHS, all clinics across all specialities are covered by CQC. However a practitioner who works NHS and in private care would still need an additional CQC registration for their private works, they can not use NHS provision for private work. 4). All practitioners must also be registered with the governing body of their speciality also, such as NMC, GMC, GDC. ALL practitioners must be either a NURSE/MIDWIFE/DOCTOR/DENTIST/HEALTH VISITOR who has taken on the additional tongue-tie training. It is out-of-scope for an IBCLC without this training to be diagnosing or dividing tongue tie restrictions. Similarly it is not part of routine training for midwives, health visitors or GPs to diagnose either. They can provide you with their valid opinion and insight, just not a formal diagnosis. In an ideal world those professionals should say "I suspect........but here are the details of a professional who is trained to diagnose and support in this area as I am not trained in this specialism". I am not suggesting NHS refer into private practice nor that individual names are used, but signposting to a professional body for primary caregivers to make an informed choice is the correct thing to do. And ruling it out is just as important as ruling it in too! 5). The Association of Tongue Tie Practitioners (ATP) UK. The ATP list all of the practitioners who have registered with them geographically in a handy map, with a search tool to locate who is closest to your area or by postcode. Annually the ATP check these practitioners are registered with CQC and their governing body, but ultimately it is upto the primary caregiver to check the credentials of their chosen practitioners. www.tongue-tie.org.uk/find-a-practitioner/ The ATP website also houses additional information for parents such as what to expect at an appointment, what symptoms are associated with tongue-tie restriction and many more. © Diana Warren IBCLC, RGN D-Restricted Ltd

WHAT IS A LIP-TIE AND DOES IT NEED TREATMENT? A lip tie diagnosis and division is a very grey area in UK; USA practitioners divide alongside a tongue tie release, but current research, inclusive of labial and buccal ties does suggest that isn't necessary. My understanding is that issues with lip-ties are more dentally related and regular dental visits as normal and routine are suggested. A lingual lip-tie is normal anatomy-everybody has one-and they tend to recede as one grows anyway-particularly when adult teeth come through. However, should you suspect your little one has one, once you do start weaning onto solid foods: be sure to remove any food debris from either side of the tie as held against the gum or tooth may cause decay. There is also new research I read recently that suggested that even if a lip tie was divided, unless bone was removed then it would usually reform/reattach anyway as the upper lip has not technically got to move in order to allow for a good nutritional intake. It is also a very vascular area so blood loss is generally higher in comparison to most tongue-tie releases. The best profession to get further info on this is the infant’s dentist or an oral surgeon qualified in this area as they can address or signpost any issues. Some oral surgeons and dental surgeons may consider a division should they agree it is impacting the individual's growth. It is also worth mentioning that many perceived lip tie problems are actually tongue tie related-and once tongue function reaches optimum motility the symptoms alleviate. Sometimes a lip tie can affect the ‘vacuum draw’ of getting breast into a correct breast feeding position but this does not prevent a successful pain-free breastfeed, can be addressed with correct positioning and attachment techniques, and can be subjective. You may find these helpful: https://abm.me.uk/wp-content/uploads/2017/03/Spring-2017-feature-article.pdf www.tongue-tie.org.uk/position-statements/ http://www.analyticalarmadillo.co.uk/2015/01/upper-lip-tie-fall-guy.html?m=1 ​© Diana Warren IBCLC, RGN D-Restricted Ltd

What is the 'deal' with REFORMATION? The term 'reformation' can mean different things to different professionals and primary caregivers alike. Here, I will explain my understanding of this term. It is important to understand that different practitioner's and healthcare professionals will have slightly varied versions to my own, it does not mean that they are wrong, just that unfortunately there is no universal definition in correlation to a tongue tie release. Reformation; also known as 're-occurence', re-adherence', 're-growth' or 're-attachment' A survey conducted by the Association of Tongue Tie Practitioners in the UK published to its members in 2021, found that out of a total of 9365 total frenulotomy procedures, 3.03% patients required a second divide. Now, there may be a number of reasons why a second frenulotomy procedure is required, and similarly it may be that not all primary caregiver's of the infant with reformation would come forward to arrange a reassessment so this figure could potentially be higher for those that are unknown, but this figure does fall inline with the global average figure so is a good base line. Your individual chosen practitioner may do their own audit on their annual reformation rate too, but that said; it is not technically a reflection on their ability, reformation has many causes of which Mother Nature is more to blame than individual practitioner accountability. It is important to note that it is entirely NORMAL ANATOMY to have a visible frenulum, both before AND AFTER a frenulotomy (tongue tie procedure). Everybody has one, we all need one, they are all just placed at different points so some are more visible than others. The question at any stage really is: Is the frenulum causing issues with tongue function and motility? To know this, there would be adverse feeding symptoms, which would indicate the need for further assessment. Infant feeding is one of the hardest things the tongue will need to do in a lifetime, so please ensure that your chosen provider is a registered infant feeding specialist, who also provides some form of aftercare support you are happy with (see BLOG POST "Who can provide a tongue-tie release?") So, 'Reformation' itself, I believe is very much an umbrella term and one of a few things can happen: Following frenulotomy procedure, feeding ability improves over time as the oral structures regain strength. Although you may see some visible frenulum once the wound has visually healed this is considered normal anatomy, this is NOT reformation and is the desired outcome. Scar Tissue: This can be fibrous and taut caused by the original division and can pose a restriction. This is not a fault of the practitioner, it is how some people heal. Mother Nature is in charge of this one. The good news though is that in time most scars do soften over time, but we are not in a position to have the knowledge of who will or won't scar. If you are aware of any family history of scarring issues, such as keloid scarring, it maybe something you wish to consider before making any decisions for initial division. It could be that there is residual tension in the body. Now there are a whole range of causes for this ranging from being engaged for too long, shape of maternal pelvis, c-section deliveries, instrumental or quick deliveries, right through to the tongue tie restriction itself. It's plausible that most infants would have a collection of reasons for tension in their little bodies, we do not believe it to be painful as many do not display signs of pain, but generally there may be a whole matrix web of tensions in different direction which is affecting the coordination and ability to feed effectively. This is usually resolved with time, changes in feeding positions and bodytherapies (such as @Baby-Myo', 'Osteopathy', 'Chiropractic' or 'Crainio-Sacral Therapy'. Some practitioners would suggest some tongue function exercises too which are also helpful (NOT to be confused with wound massage or stretches-see BLOG post "Post procedure tongue-function exercises"). It may be that your chosen practitioner was not able to get all of the restrictive tissue, so an incomplete divide. This may be due to anatomical limitations or structures, blood loss etc. Historically, a full division was always determined by getting a 'diamond-esque' shaped wound, but as all anatomy is different this is not always the case. It is super important that you research your practitioner, their credentials, reputation and experience. Unfortunately, not every practitioner falls into a profession that is regulated, and others do not 'believe' in what I term 'a posterior restriction' (there is not a universally agreed definition of posterior), and so unfortunately will only divide the anterior aspect of the frenulum which may not resolve the original feeding issues. Regrowth: Some people refer to regrowth believing it is new tissue formation at the back which is restrictive. This is tricky as how someone can determine this between the other above types is complex. However, my understanding is that it is not regrowth per se. I believe this is the normal anatomy formation as described in point 1, but has been hindered in its protrusion due to bodily tensions (ie point 3). © Diana Warren IBCLC, RGN D-Restricted Ltd