Nipple vasospasm is a temporary narrowing of the blood vessels supplying the nipple. This reduces blood flow and can cause significant pain, sometimes accompanied by visible changes in nipple colour. It may happen during breastfeeding, immediately afterwards or between feeds. The term vasospasm describes what is happening to the blood vessels. It does not, by itself, mean that someone has a medical condition. Nipple compression during feeding can also contribute to vasospasm, particularly when positioning and attachment are not comfortable or effective (The Breastfeeding Network, 2019; NHS, 2026). Understanding the possible causes is important because the most helpful approach depends on what is contributing to the symptoms. Recognising nipple vasospasm Pain associated with nipple vasospasm is often described as burning, stabbing, shooting, throbbing or tingling. Some people experience a sharp pain as the nipple becomes pale, followed by throbbing or burning as blood flow returns (The Breastfeeding Network, 2024; Deniz and Kural, 2023). The nipple may become white or pale, then develop a blue or purple appearance before returning to its usual pink or red colour. This is sometimes described as a triphasic colour change. However, not everyone experiences all three stages, and colour changes may be less apparent on some skin tones (The Breastfeeding Network, 2019; Deniz and Kural, 2023). Pain may be felt in the nipple itself or radiate into the breast. It can affect one or both breasts and may last for several minutes after feeding. The timing, character and associated symptoms can provide useful clues, but no single symptom confirms the cause (The Breastfeeding Network, 2019; Newman, 2017). Nipple compression and feeding mechanics One important contributor to nipple vasospasm is mechanical compression during breastfeeding. When a baby is not attached deeply or comfortably, the nipple may be compressed between the tongue and the roof of the baby's mouth. This can restrict blood flow and may also cause tissue trauma. When the baby releases the breast, the change in pressure and return of blood flow can trigger pain. The shape of the nipple after a feed can provide a useful clue. A nipple that appears flattened, ridged, creased, wedged or lipstick-shaped may have been compressed during feeding. A white or pale area may also be visible. These findings need to be considered alongside the feeding assessment rather than used in isolation (NHS, 2026; The Breastfeeding Network, 2019). The priority is to understand why the nipple is being compressed and address the underlying feeding mechanics. A skilled assessment should consider more than the position of the baby's mouth. It includes: How the baby is positioned in relation to the feeding parent. Whether the baby's whole body is close, supported and appropriately aligned. Whether the baby's head is free to move, including the ability to extend their head as they approach and attach to the breast. How the baby approaches the breast and achieves attachment. Whether the baby can maintain a comfortable attachment throughout the feed. Whether the baby is transferring milk effectively. Whether oral function may be influencing the way the baby attaches and feeds. There is no single breastfeeding position that works for every feeding dyad. The aim is to find an arrangement that allows the baby to approach the breast comfortably, move their head freely and achieve an effective attachment without unnecessary pressure on the nipple. Changing position repeatedly without understanding why the nipple is being compressed may not resolve the problem. The important step is to identify what is happening during feeding and make appropriate changes. You may find these articles helpful: Breastfeeding latch and positioning How to improve infant latch: practical breastfeeding support Painful breastfeeding latch: support that helps A guide to understanding your baby's oral function A visible lingual frenulum does not, by itself, establish that a baby has a functionally restrictive tongue-tie or explain nipple pain. Oral anatomy needs to be considered alongside function and the wider feeding picture. Raynaud's phenomenon Raynaud's phenomenon is a vascular condition in which small blood vessels temporarily narrow in response to particular triggers. It most commonly affects the fingers and toes, but it can also affect the nipples (The Breastfeeding Network, 2019; Ujueta et al., 2026). Cold is a recognised trigger. Emotional stress can also trigger episodes of Raynaud's phenomenon by influencing vascular responses. This does not mean that emotional stress is the cause of an individual's nipple pain, or that symptoms are simply related to anxiety (Ujueta et al., 2026). When Raynaud's affects the nipple, pain may be particularly noticeable after feeding when the nipple is exposed to cooler air. The nipple may become white, blue or purple before returning to its usual colour as circulation recovers. A history of Raynaud's symptoms elsewhere, circulation problems or migraines may provide additional information during assessment. However, nipple vasospasm can occur without a previous diagnosis of Raynaud's phenomenon (The Breastfeeding Network, 2019). It is useful to distinguish between compression-related vasospasm and Raynaud's phenomenon. If nipple compression is contributing to the symptoms, improving positioning and attachment is a priority. If pain and colour changes continue despite comfortable, effective feeding, Raynaud's may need further consideration. Mammary constriction syndrome Mammary constriction syndrome (MCS) is a term used to describe deep breast pain associated with sustained tension in the pectoral muscles beneath the breast (Kernerman and Park, 2014). Poor breastfeeding posture, prolonged periods of holding the baby in an uncomfortable position, or tightening the shoulders and chest in anticipation of a painful latch may contribute to muscular tension. This can be associated with deep breast discomfort rather than pain confined to the nipple. The pain may be described as aching, stabbing or shooting and can be felt through the breast and chest area. Dr Jack Newman has also discussed referred or radiating pain, where discomfort originating in the nipple is felt elsewhere in the breast (Newman, 2017). Where poor posture or uncomfortable positioning is contributing to muscular tension, the priority is to correct the underlying problem. Improving the baby's positioning and attachment, supporting the feeding parent's posture and avoiding sustained tension are important. Pectoral massage or stretching may be considered as an adjunct, but should not replace addressing the feeding mechanics. Further information is available in Mammary Constriction Syndrome. Other factors that may contribute to nipple pain Not all nipple pain is caused by vasospasm. Skin conditions, nipple damage and other breast or nipple problems may cause discomfort or occur alongside feeding-related pain. Dermatitis and eczema can affect the nipple and areola. The skin may appear dry, flaky, red, itchy, cracked or inflamed. Irritant or allergic contact dermatitis can occur following exposure to products applied to the skin, including nipple creams, cleansers, breast pads or laundry products. Persistent skin changes need appropriate assessment rather than being assumed to be vasospasm (Jones, 2024). Lanolin, which is commonly included in nipple creams, can also cause problems for some people. Although it is often marketed to soothe sore nipples, it can trigger contact irritation or an allergic reaction. Applying lanolin to already fragile, sore or damaged nipple and areolar skin may cause stinging, discomfort or worsening pain. This is worth considering if symptoms began or became worse after using a lanolin-containing product (Moore and Stevenson, 2025). Medication history is also worth considering. Some medicines can influence vascular responses, and it is helpful for a healthcare professional to know about prescribed medicines, over-the-counter preparations and supplements. Do not stop or change prescribed medication without discussing it with the prescriber. SSRIs are sometimes discussed in the context of persistent pain, but this does not establish that they are a treatment for nipple vasospasm or that they are responsible for an individual's symptoms. The evidence for pharmaceutical treatment of lactation-related nipple pain remains limited and contested (Douglas, 2022). Expressing and nipple vasospasm Nipple pain can also occur during or after expressing milk. If symptoms are associated with pumping, the equipment and the way it is being used need to be considered. A flange that is unsuitable in size or shape, excessive suction, friction or repeated pulling of the nipple and areola into the tunnel may contribute to discomfort and tissue trauma. Increasing suction is not necessarily the answer and may make discomfort worse (Amir et al., 2021). A review of expressing should consider the movement of the nipple within the flange, whether the breast is being drawn into the tunnel, the level of suction, cycle settings, comfort and the amount of time spent expressing. Hand expression can also cause discomfort if the nipple itself is pinched or pulled rather than pressure being applied behind the nipple to move milk forwards. The following articles provide further information: How to express breastmilk Flange fit assessment: what good fit considers Breast pump flange fitting: size, shape, comfort and milk removal Measures that may help The most useful measures depend on the cause of the symptoms. Where nipple compression is contributing, correcting positioning and attachment is the priority. Comfort measures alone will not resolve an ongoing mechanical problem. Where cold is a trigger, some people find it helpful to: Keep the breasts and nipples warm between feeds. Cover the nipple promptly after feeding rather than leaving it exposed to cold air. Avoid sudden changes in temperature where possible. Use a comfortably warm compress after feeding. Avoid applying anything excessively hot to the nipple, particularly when sensation is altered. If caffeine appears to make symptoms worse, it may be worth considering whether reducing intake changes the pattern. Avoid smoking and nicotine, which can affect blood vessels. These measures may help some people, but they should not be treated as a substitute for assessing the underlying cause (The Breastfeeding Network, 2019; The Breastfeeding Network, 2024). If you are expressing, check that your pump settings and flange fit are comfortable. Persistent pain during expressing deserves assessment too. Keeping a note of symptoms It may be helpful to notice when the pain occurs and whether there are any patterns. For example, does it happen at the initial latch, continue throughout the feed, begin immediately afterwards or occur between feeds? Is it burning, stabbing, shooting or throbbing? Does it happen during breastfeeding, expressing or both? Does it seem worse at a particular time of day, overnight, following exposure to cold or at a particular point in the menstrual cycle? However, keeping a diary is entirely optional. It is not intended to add to maternal workload, create another task to complete or encourage families to analyse figures. There is no need to measure, score or record every episode of pain. The priority is a skilled infant feeding specialist observing a complete feed. Seeing what happens throughout the feed provides important information about positioning, attachment, oral function, nipple compression and milk transfer. A diary may add context, but it is not a substitute for that assessment. Getting the right support If nipple pain is persistent, recurrent or affecting your ability to feed comfortably, seek support rather than feeling you have to manage it alone. An appropriately qualified infant feeding specialist can observe a complete feed and assess positioning, attachment, nipple shape and colour, and how your baby is transferring milk. If expressing is involved, the assessment may also consider pump use and flange fit. Where pain continues despite comfortable and effective feeding, or there are symptoms suggesting Raynaud's phenomenon, a medical assessment may be appropriate. A GP may consider whether there are other contributing factors and whether further investigation or treatment is needed. Medication may be considered in some circumstances, but decisions need to be made by an appropriately qualified prescriber following an individual assessment. Evidence for medication specifically to treat lactation-related nipple vasospasm is limited, and potential benefits need to be considered alongside side effects and the wider clinical picture (Douglas, 2022). For information about medicines and breastfeeding, the Breastfeeding Network's Raynaud's factsheet and its Drugs in Breastmilk service are useful sources of further information. A pharmacist or prescriber can also help review medication questions. Do not stop or change prescribed treatment without seeking advice. Seek prompt medical advice if you develop a hot, swollen or increasingly painful area of breast tissue, fever, flu-like symptoms or feel generally unwell. Persistent nipple skin changes, cracking, bleeding, ulceration or a new breast lump also need assessment. If your baby is feeding less effectively, has fewer wet nappies than expected, is unusually sleepy or there are concerns about weight gain, seek timely assessment of their feeding and health (NHS, 2026). Looking after your emotional wellbeing Breastfeeding or expressing with ongoing pain can be physically and emotionally exhausting. It is important to recognise the impact this may have on maternal mental health, particularly if pain is affecting sleep, confidence or how you feel about feeding. Be kind to yourself and remember that you do not have to simply put up with pain. You deserve care and support too. Make time for rest and self-care where possible, and talk to someone you trust or a healthcare professional if you are finding things difficult emotionally. References Amir, L.H., Baeza, C., Charlamb, J.R. and Jones, W. (2021) ‘Identifying the cause of breast and nipple pain during lactation’, BMJ, 374, n1628. doi:10.1136/bmj.n1628. Deniz, S. and Kural, B. (2023) ‘Nipple vasospasm of nursing mothers’, Breastfeeding Medicine, 18(6), pp. 494–498. doi:10.1089/bfm.2023.0024. Douglas, P. (2022) ‘Re-thinking lactation-related nipple pain and damage’, Women's Health, 18. doi:10.1177/17455057221087865. Jones, W. (2024) ‘Eczema, dermatitis and breastfeeding’. Breastfeeding and Medication. Kernerman, E. and Park, E. (2014) ‘Severe breast pain resolved with pectoral muscle massage’, Journal of Human Lactation, 30(3), pp. 287–291. doi:10.1177/0890334414535842. Moore, H. and Stevenson, A. (2025) ‘Breast and nipple dermatoses during lactation’, Australasian Journal of Dermatology, 66(7), pp. e386–e407. doi:10.1111/ajd.14586. Newman, J. (2017) ‘When it hurts to breastfeed: Part 2’, International BreastFeeding Centre, 27 September. NHS (2026) ‘Breast pain and breastfeeding’. NHS. NHS (2026) ‘Sore or cracked nipples when breastfeeding’. NHS. The Breastfeeding Network (2019) ‘Raynaud’s phenomenon in breastfeeding mothers’. The Breastfeeding Network (2024) ‘Pain: If breastfeeding hurts’. Ujueta, F., Goudot, G., Cutolo, M., Dolan, R., Hoffman, C., Desai, M. and Gerhard-Herman, M. (2026) ‘Primary and secondary Raynaud: a scientific statement from the American Heart Association’, Circulation, 154(13), pp. e505–e517. doi:10.1161/CIR.0000000000001464.

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

Breastfeeding oversupply, also known as hyperlactation or hypergalactia, occurs when a lactating person produces more breastmilk than their baby or babies need. It can cause persistent breast fullness, leaking, recurrent blocked areas and breast inflammation, as well as feeding difficulties for a baby who struggles to manage the volume or speed of milk flow. Babies may have difficulty maintaining attachment, cough or splutter during feeds, become unsettled and experience gastrointestinal symptoms, including explosive green, frothy stools. Weight gain may be faster or slower than expected, depending on how effectively the baby is able to feed and transfer milk (Trimeloni and Spencer, 2016; Johnson et al., 2020). The aim of management is not simply to reduce milk production because a baby finds the flow difficult. It is to establish whether there is genuinely more milk being produced than the baby needs, identify what may be contributing to it and support comfortable feeding while protecting the baby's intake and the lactating person's breast health. Understanding breastmilk production Milk is produced by secretory cells within the alveoli of the breast. During pregnancy, hormonal changes prepare the breast for lactation. Following birth, the delivery of the placenta causes progesterone levels to fall. In the presence of prolactin, this change initiates secretory activation, when milk production increases substantially. Oxytocin is responsible for the milk ejection reflex, allowing milk to move from the alveoli towards the nipple during feeding or expression (Neville, 2023). Once lactation is established, milk production is increasingly regulated by local mechanisms within the breast. The amount and frequency of milk removed influence subsequent production. Regular and effective milk removal supports continued production, while milk remaining in the breast contributes to local signals that slow milk synthesis (Brodribb, 2018; Johnson et al., 2020). This means that additional milk removal can increase production beyond the amount required by the baby. Repeated expressing after effective breastfeeds, collecting substantial volumes from the opposite breast during feeds or continuing an expressing routine after it is no longer needed may all contribute to oversupply (Johnson et al., 2020). Milk production can also be influenced by medication and substances taken with the intention of increasing supply. Galactagogues include prescribed medicines such as domperidone and metoclopramide, as well as herbal products. Their effects and safety vary, and their use should be considered in the context of an individual's health, medication history and feeding circumstances (Brodribb, 2018; Johnson et al., 2020). Causes of oversupply Oversupply may have several contributing factors. Understanding how milk production is being stimulated and how effectively the baby is removing milk is important when identifying the cause. Ineffective milk removal and additional expressing A baby who is unable to remove milk effectively may feed frequently, remain at the breast for prolonged periods or appear unsettled after feeds. Ineffective milk transfer does not, in itself, cause oversupply. However, it can lead to additional expressing being introduced to maintain or increase milk production. If milk is then removed in addition to what the baby needs, this can contribute to production exceeding the baby's requirements. It is therefore important to assess the baby's ability to transfer milk before recommending changes to milk production. This includes considering attachment, oral function, sucking, swallowing and feeding coordination, alongside the baby's weight trajectory and feeding behaviour. Expressing may be necessary when a baby cannot transfer milk effectively, when a parent and baby are separated or when milk production needs to be maintained. However, the amount and frequency of expression should reflect the reason for expressing and the needs of the feeding dyad. Repeatedly expressing after feeds, collecting substantial volumes from the opposite breast or continuing an expressing routine after it is no longer necessary may stimulate production beyond the baby's requirements (Johnson et al., 2020). Iatrogenic oversupply Oversupply can sometimes develop following advice or a care plan that encourages additional milk removal or the use of galactagogues. These interventions may be appropriate in particular circumstances, but they need to be reviewed as the baby's feeding and milk-transfer abilities change. A plan that was initially necessary may no longer be appropriate once the baby is feeding more effectively. The Academy of Breastfeeding Medicine (ABM) describes iatrogenic hyperlactation as excessive milk production arising from healthcare interventions, including additional expressing or galactagogues, where these contribute to production exceeding the baby's needs (Johnson et al., 2020). Medication and galactagogues Some prescribed medicines and herbal products can increase milk production. Galactagogues include medicines such as domperidone and metoclopramide, as well as herbal products. Their effects and safety vary, and their use should be considered in the context of an individual's health, medication history and feeding circumstances. The ABM identifies medicines used as galactagogues as a possible contributor to excessive milk production (Johnson et al., 2020). Prescribed medicines should not be stopped or changed without advice from the prescribing clinician. Herbal products should not be assumed to be harmless simply because they are marketed as natural. Idiopathic oversupply Some lactating people produce more milk than their baby needs despite not deliberately stimulating additional production and without an identifiable cause. This is described as idiopathic hyperlactation. Breast fullness and higher milk production are common during the early weeks while lactation is becoming established. They do not necessarily indicate persistent oversupply. The ABM identifies idiopathic hyperlactation as a diagnostic consideration when high production and associated symptoms persist without a clear explanation (Johnson et al., 2020). Recognising possible signs of oversupply Oversupply is assessed using the combined information from the lactating person, the baby and the feeding pattern. The clinical picture is more informative than any single observation. Possible signs in the lactating person include: Persistent or frequent breast fullness, including soon after feeds. Copious or frequent milk leakage. Recurrent engorgement. Recurrent blocked areas or breast inflammation. Breast or nipple discomfort associated with fullness or forceful milk ejection. A baby who regularly feeds from one breast only because of the volume available. Possible signs in the baby include: Coughing, spluttering, gulping or repeatedly pulling away when milk begins to flow. Difficulty coordinating sucking, swallowing and breathing during feeds. Difficulty maintaining a sustained, deep latch. Clamping down on the nipple or areola to try to manage the flow. Coming on and off the breast, sometimes becoming upset or frustrated. Short feeds, tiring quickly or frequent feeding. Swallowing air, appearing windy or having frequent episodes of abdominal discomfort. Frequent spitting up. Explosive green, frothy stools. Irritability or fussing during or after feeds. Weight gain that is faster than expected, although some babies may gain less quickly if feeding difficulties affect milk transfer. Green, frothy stools are a recognised clinical sign associated with oversupply. They should be considered as part of the wider assessment, alongside the baby's weight trajectory, feeding behaviour, irritability, fussing, wind, milk-flow difficulties and the lactating person's breast symptoms. Trimeloni and Spencer (2016) identify large, frothy stools as a possible feature of oversupply, while the ABM includes explosive green stools among the gastrointestinal symptoms associated with hyperlactation (Johnson et al., 2020). The traditional explanation that green, frothy stools simply reflect an imbalance between 'foremilk' and 'hindmilk' can be misleading. Milk composition changes during a feed, but it is not divided into two distinct types. The volume and speed of milk intake, alongside the wider feeding picture, need to be considered rather than attributing stool changes to a simple foremilk/hindmilk imbalance. Weight gain is particularly important when interpreting the wider picture. Some babies with oversupply gain weight rapidly, while others may not gain as expected if feeding difficulties interfere with effective milk transfer. A baby's growth pattern, rather than a single weight measurement, helps establish whether intake is meeting their needs (Trimeloni and Spencer, 2016; Johnson et al., 2020). Oversupply and fast milk flow Breastfeeding oversupply can contribute to fast milk flow. When the breast produces more milk than the baby needs, increased fullness and pressure can result in a more forceful flow, particularly during milk ejection. This may make it difficult for a baby to coordinate sucking, swallowing and breathing, and can lead to coughing, spluttering, pulling away or becoming unsettled during feeds (Johnson et al., 2020). However, fast milk flow does not always indicate oversupply. A lactating person may have an appropriate milk supply but experience a forceful milk ejection reflex, resulting in a rapid flow of milk. This distinction is important because reducing milk production is not necessarily appropriate when the difficulty relates to the speed of milk ejection rather than excessive production. Nancy Mohrbacher (2013) highlights this distinction in her discussion of block feeding. She describes how babies may struggle with milk flow without the lactating person necessarily having excessive production. She cautions against reducing milk production when it is already appropriate, as doing so may contribute to problems such as slower weight gain. It is therefore important to establish whether the baby is struggling with a fast flow because of excessive production, a forceful milk ejection reflex or another feeding-related factor. For further information, see Fast milk flow during breastfeeding and bottle feeding. Starting with a feeding assessment Before trying to reduce milk production, it is important to understand what is happening during feeding and why oversupply is suspected. An assessment should consider: The baby's age, gestation, health and weight trajectory. Feeding frequency, duration and behaviour during feeds. Whether the baby is transferring milk effectively. Positioning, attachment and the baby's ability to coordinate sucking, swallowing and breathing. Whether the baby is struggling mainly during the initial milk ejection or throughout the feed. The lactating person's breast fullness, comfort, leaking and history of breast inflammation. Any additional expressing, pumping or milk collection. Medicines, supplements and galactagogues. How long the current feeding and expressing pattern has been in place. It is particularly important to assess milk transfer. A baby may struggle with a fast flow but still transfer milk effectively. Another baby may appear to feed frequently or for prolonged periods because they are not removing milk efficiently. These circumstances require different approaches. An assessment should also consider whether there are other explanations for the baby's symptoms. Persistent coughing or choking, difficulty coordinating feeding, repeated vomiting, marked tiredness during feeds or concerns about growth warrant appropriate clinical assessment. Managing milk flow during breastfeeding Where the baby is growing well and feeding comfortably, intervention may not be necessary. If milk flow is causing difficulty, some adjustments may help. Positioning A laid-back or reclined breastfeeding position may help some babies manage a forceful flow. In this position, the baby feeds against the lactating person's body and gravity may help slow the movement of milk towards the baby's mouth. The baby is not positioned directly beneath the breast with milk flowing downhill into their mouth, which may give them greater control over the flow. Other babies may manage better in a more upright or side-lying position. There is no single position that suits every feeding dyad. The aim is to find a comfortable position that allows the baby to maintain a secure attachment and coordinate feeding without being overwhelmed by the flow (Mohrbacher, 2013; Johnson et al., 2020). See Breastfeeding latch and positioning for further information. Managing the initial milk ejection If the baby repeatedly pulls away or struggles when milk first begins to flow, briefly detaching them may help. The lactating person can allow the strongest initial flow to subside before offering the breast again. If the breast is very full and milk is flowing forcefully, a small amount may be hand expressed to release the free-flowing milk and ease the initial pressure. This should not become a routine of expressing until the breast feels empty, as removing substantial additional milk can stimulate further production (Johnson et al., 2020). Once the strongest flow has subsided, the baby may be able to reattach and manage the milk flow more comfortably. This can also allow them to establish a more effective latch and continue removing milk. Subsequent milk ejections Milk ejection can occur more than once during a feed. Some babies manage these subsequent flows without difficulty, while others may pull away or become unsettled when milk begins to flow more quickly again. There is no need to anticipate or interrupt every milk ejection if the baby is feeding comfortably. If a baby is struggling, a pause may help until the strongest flow has subsided. The response should be guided by what is happening during that particular feed rather than following a rigid routine. Expressing for comfort If the breasts are uncomfortably full, expressing a small amount of milk may help relieve pressure. The intention is to improve comfort, not to empty the breast. Repeatedly expressing larger volumes can maintain or increase milk production. This is particularly important when a person is already expressing in addition to breastfeeding. If an expressing routine has contributed to oversupply, the amount and frequency may need to be reviewed gradually (Brodribb, 2018; Johnson et al., 2020). Further information is available in How to express breastmilk. Silicone milk collectors and suction-based pumps Silicone milk collectors are not all the same. Some devices are designed to catch milk that leaks spontaneously, while others attach to the breast using suction and actively remove milk. A passive milk catcher does not work in the same way as a suction-based silicone pump. A suction-based device can remove additional milk and may also provide stimulation that contributes to maintaining or increasing production. Katherine Scott (2024), an American registered nurse and IBCLC, discusses her concerns about silicone pumps such as the Haakaa in her article Let's talk about silicone breast pumps (aka Haakaa). She distinguishes these suction-based devices from passive milk catchers, such as the Ladybug and other collection devices. Scott describes the continuous suction applied by silicone pumps and reports seeing nipple and duct damage, as well as blocked ducts around the areola. She attributes these concerns to sustained pressure and the amount of nipple and areola drawn into the device. Scott's article is a clinical practitioner's account of her observations and experience, rather than a controlled research study establishing the frequency or long-term effects of injury. It is nevertheless important to consider the potential effects of continuous, uncontrolled suction and pressure on nipple and breast tissue. The longer-term effects of repeated or prolonged suction on nipple duct openings and ducts have not been adequately established, and further research is needed. The manufacturer's instructions for the Medela Silicone Breast Milk Collector also advise users to ensure that the device does not press on the milk ducts of the nipple. This reinforces the importance of correct positioning and avoiding unnecessary pressure (Medela AG, 2022). Where the aim is simply to catch milk that would otherwise leak, a passive milk catcher may be more appropriate than a device that applies continuous suction. Where a suction-based collector is used, families should consider whether the additional milk removal is necessary and whether the device is causing discomfort, nipple changes or blocked areas. Block feeding Block feeding is a method used to reduce milk production by allowing one breast to remain fuller for a set period before switching to the other breast. The local feedback mechanisms within the breast respond to retained milk by slowing production. Block feeding can be effective when there is genuine oversupply, but it is not a first-line response to every baby who struggles with milk flow. Reducing milk production unnecessarily can affect the baby's intake and may create a new feeding problem. When block feeding may be considered Block feeding may be considered where there is a clear pattern of oversupply and the usual adjustments to feeding and milk removal have not been sufficient. The decision should take account of the lactating person's breast symptoms, the baby's feeding behaviour, milk transfer and weight trajectory. It is particularly important to establish that the baby is able to remove milk effectively. If milk transfer is already inefficient, reducing production may make it harder for the baby to obtain enough milk. Nancy Mohrbacher (2013) cautions against assuming that coughing, spluttering or pulling away automatically indicate oversupply. She explains that young babies are still developing the coordination needed to manage milk flow and that some difficulty is not unusual in the early weeks. Where weight gain is not unusually high, she suggests considering feeding positions that give the baby more control over milk flow rather than immediately reducing production. Mohrbacher describes block feeding as potentially helpful where there is genuine oversupply, but advises that it should not continue for longer than one week in the circumstances she discusses. She uses a particular weight-gain comparison in her article: during the first three months, she describes average gain as approximately 2 lb (0.9 kg) per month and suggests that block feeding may be considered where a baby is gaining at twice that rate or more. This is her suggested guide, not a universal diagnostic threshold. It should not be applied without considering the individual baby's growth, feeding history and clinical circumstances. She also emphasises that persistent difficulty managing milk flow warrants assessment by a lactation professional, including consideration of the baby's anatomy, swallowing and breathing (Mohrbacher, 2013). Individualising the block-feeding plan The duration of each block should be determined according to the individual feeding dyad. There is no single time period that is appropriate for everyone. The plan may need to be divided differently during the day and overnight, and the duration may need to change as milk production responds. The Academy of Breastfeeding Medicine's Clinical Protocol #32 describes block feeding as an intervention for idiopathic hyperlactation and recommends close supervision by a clinician knowledgeable in breastfeeding care. Its 2020 protocol gives an example of feeding from one breast for three-hour periods during the day, alternating sides for each block, with unrestricted feeding from both breasts overnight. This is an example within the protocol, not a universal schedule. The ABM emphasises that management should be modified for individual circumstances and monitored throughout (Johnson et al., 2020). If the other breast becomes uncomfortably full during a block, a small amount of milk can be expressed for comfort. It is not necessary to empty the breast. The baby should continue to be fed responsively, and feeding cues should not be ignored to maintain a block schedule. Block feeding can reduce production too far or too quickly. Potential complications include blocked ducts, breast inflammation, mastitis, reduced milk intake and poor infant weight gain. It may also be difficult for a baby to adapt to a rigid schedule. For these reasons, block feeding should only be undertaken with the oversight of an appropriately qualified and experienced breastfeeding professional or clinician. The plan needs regular review, including the baby's weight and intake, the lactating person's breast comfort and any signs that milk production is falling below the baby's needs. The ABM specifically recommends close supervision and ongoing monitoring because of the potential for maternal complications and inadequate infant weight gain (Johnson et al., 2020). Block feeding should not be used simply because a baby coughs, splutters or comes off the breast. Where the main difficulty is fast flow rather than excessive production, positioning and feeding support may be more appropriate. Protecting breast health while supply adjusts Reducing milk production needs to be gradual enough to avoid creating additional breast discomfort or inflammation. Abruptly reducing milk removal can result in excessive fullness and may increase the risk of blocked areas and mastitis (Johnson et al., 2020). If expressing has contributed to oversupply, the amount or frequency may need to be reduced carefully rather than stopped suddenly. Expressing for comfort can help manage fullness while production adjusts, but repeated removal of substantial volumes may maintain the problem. Persistent or worsening breast pain, redness, swelling or flu-like symptoms need appropriate assessment. A person who develops a fever, feels unwell or experiences increasing breast inflammation should seek advice promptly. Supporting the feeding dyad Oversupply can be physically uncomfortable and emotionally demanding. Repeatedly leaking, feeling full between feeds, experiencing breast inflammation or watching a baby struggle with milk flow can make feeding stressful. Support should focus on understanding the cause of the problem rather than simply trying to reduce milk production. Some feeding dyads need only small changes to positioning or the management of the initial milk ejection. Others may need a more detailed assessment of milk transfer, expression patterns, medication or breast health. Where oversupply is suspected, an appropriately experienced infant feeding professional or International Board Certified Lactation Consultant (IBCLC) can help assess the feeding dyad and develop a plan. Medical assessment may also be needed where there are concerns about the lactating person's health, recurrent breast inflammation or the baby's feeding, swallowing or growth. The aim is to support comfortable feeding, protect the baby's intake and allow milk production to adjust towards the amount needed. For further information about professional feeding support, see: What does an infant feeding specialist do? What is an IBCLC? Feeding support explained When can a lactation consultant support you? Protecting maternal mental health Breastfeeding oversupply can be exhausting. Persistent breast fullness, leaking, repeated feeding difficulties and the need to manage milk flow or express for comfort can make everyday life demanding. When a baby is also unsettled during feeds, frequently bringing milk back up, coughing, spluttering or appearing uncomfortable, the experience can become physically and emotionally draining. It can be difficult to feel confident about feeding when each feed brings another challenge. Some families may find themselves constantly anticipating the next feed, worrying about whether their baby is getting enough milk or trying different approaches to make feeding more comfortable. The additional work involved in managing oversupply should not be underestimated. Protecting maternal mental health needs to be part of the management plan. This means listening to how the lactating person is coping, acknowledging the impact of feeding difficulties and considering what practical support might reduce the pressure. This could include help with household tasks, opportunities to rest, support from family or caregivers and access to consistent, knowledgeable infant feeding support. A management plan should be realistic and should not create further unnecessary demands. The aim is to improve feeding comfort and protect the baby's intake without placing the entire responsibility for resolving the problem on the lactating person. Families do not have to manage these difficulties alone. Practical feeding support may be available from a midwife, health visitor, IBCLC or local breastfeeding support service. The National Breastfeeding Helpline (0300 100 0212) is available 24 hours a day, and the Breastfeeding Network can help families find local support. If the emotional impact is becoming difficult to manage, a GP, midwife or health visitor can help families access further support. This may include NHS Talking Therapies or referral to a specialist community perinatal mental health team. The PANDAS Foundation also provides confidential support to families affected by perinatal mental illness. NICE recognises that feeding concerns and fatigue can affect emotional wellbeing and the developing relationship between a parent and baby. If feeding difficulties are affecting mood, increasing anxiety or making it difficult to cope, it is important to seek support early rather than waiting until things feel unmanageable (NICE, 2021). Persistent low mood, anxiety or feelings of hopelessness should not be dismissed as simply part of having a new baby. Families deserve support with their emotional wellbeing as well as their feeding difficulties. References Brodribb, W. and the Academy of Breastfeeding Medicine (2018) ‘ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018’, Breastfeeding Medicine, 13(5), pp. 307–314. doi: 10.1089/bfm.2018.29092.wjb. Johnson, H.M., Eglash, A., Mitchell, K.B., Leeper, K., Smillie, C.M., Moore-Ostby, L., Manson, N., Simon, L. and the Academy of Breastfeeding Medicine (2020) ‘ABM Clinical Protocol #32: Management of hyperlactation’, Breastfeeding Medicine, 15(3), pp. 129–134. doi: 10.1089/bfm.2019.29141.hmj. Medela AG (2022) Silicone Breast Milk Collector: Instructions for Use. Medela AG. Available at: https://shop.medela.co.uk/wp-content/uploads/2022/09/Silicone-Breast-Milk-Collector-Instructions-for-Use.pdf Mohrbacher, N. (2013) ‘Block Feeding Dos & Don’ts’, 9 October. Available at: https://nancymohrbacher.com/blogs/news/block-feeding-dos-donts National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194 Neville, M.C. (2023) ‘Lactation in the human’, Animal Frontiers, 13(3), pp. 71–77. doi: 10.1093/af/vfad021. NHS (2025) Postnatal depression. Available at: https://www.nhs.uk/mental-health/conditions/postnatal-depression/ Scott, K. (2024) ‘Let’s talk about silicone breast pumps (aka Haakaa)’, Over The Moon Lactation Consulting, 14 January. Available at: https://www.overthemoonlac.com/blog/lets-talk-about-silicone-breast-pumps Trimeloni, L. and Spencer, J. (2016) ‘Diagnosis and management of breast milk oversupply’, The Journal of the American Board of Family Medicine, 29(1), pp. 139–142. doi: 10.3122/jabfm.2016.01.150164.

Breast shaping and breast compression are hands-on techniques that can support breastfeeding by helping an infant attach to the breast and improving milk transfer. They may be useful when an infant is not gaining weight as expected, when milk intake needs support or when milk production needs to be maintained or increased. The two techniques can be used separately or together, depending on the needs of the feeding dyad. These techniques can be particularly useful following tongue-tie division. An infant who has previously had restricted tongue movement may need time and support to develop more effective tongue and jaw movements and to establish comfortable attachment. Supporting and shaping the breast can help reduce the weight of the breast against the infant's chin and lower jaw, allowing the chin to move forwards. Breast compression can encourage milk flow while the infant is developing more effective feeding patterns. Smyth (2017) discusses breast shaping as one approach that may be helpful for infants with tongue restriction. These are practical feeding techniques, rather than a guarantee of improved feeding outcomes following division. They are not only relevant after frenulotomy. Breast shaping may be helpful when the breast is full, rounded, heavy or difficult for an infant to grasp, or when the nipple is relatively flat. Breast compression may be useful when an infant becomes sleepy at the breast, sucking continues but swallowing slows, or additional milk transfer is needed. Breast shaping Breast shaping involves gently supporting and compressing the breast to help an infant take a mouthful of breast tissue when attaching. The aim is to make the breast easier to grasp, with its shape aligned to the direction of the infant's lips and mouth. Why breast shaping may help Breast shape, fullness and weight can all influence how an infant approaches and attaches to the breast. Smyth (2017) describes breast shaping as a way of supporting the breast and adjusting its shape to help an infant take a mouthful of breast tissue. This may be particularly useful where the breast is rounded, the nipple is relatively flat or the infant needs additional support to achieve attachment. Where the breast is large or heavy, positioning is also important. The weight of the breast against an infant's chin or chest may make it more difficult for them to bring their chin forwards and maintain a comfortable feeding position. Supporting the breast may help, but the infant's position and the way the breast is supported need to be considered together (Smyth, 2017; Douglas and Keogh, 2017). Breast fullness and engorgement can create additional difficulties. When swelling makes the nipple and areola firm, an infant may find it harder to grasp the breast. Reverse pressure softening may help make the tissue around the nipple more pliable before attachment. This is different from breast shaping and is worth considering where engorgement or areolar oedema is contributing to the difficulty. For more information, see Breastfeeding: latch and positioning and Reverse Pressure Softening Technique for Engorgement. Breast shaping also supports the principle of bringing the baby to the breast, rather than moving the breast towards the baby and then releasing it. Moving the breast towards the infant can create tension or drag as the breast returns to its natural position. Supporting its shape while the infant attaches can help avoid this (Smyth, 2020). Choosing a hand hold The hand hold describes how the breast is supported; it does not describe the infant's feeding position. The direction in which the infant approaches the breast helps determine which hold may be most comfortable and useful. C-hold: The thumb rests above the breast and the fingers below it. The thumb and fingers are positioned in line with the infant's lips. This may be useful when the infant is lying more vertically against the caregiver's body. U-hold: The thumb and fingers support the breast from either side, with the hand positioned to align with the infant's lips. This may be useful when the infant is held across the body, such as in a cradle position. Scissor hold: The breast is supported between the forefinger and middle finger, with one finger on either side of the nipple. This is another option where the shape and direction of the breast need gentle adjustment. These are options rather than rigid rules. The most useful hold is the one that allows the breast to be supported comfortably and shaped in the direction that matches the infant's mouth (Smyth, 2017). How to use breast shaping 1. Position the infant comfortably. Bring the infant close, with their body facing the caregiver and their head and body in alignment. Position them so that their nose is approximately level with the nipple. 2. Support the breast. Use a C-hold, U-hold or scissor hold, depending on the infant's position and the direction of their mouth. Keep your fingers and thumb far enough back from the nipple and areola to leave space for the infant to attach. 3. Shape the breast. Gently compress the breast so that its shape is aligned with the infant's lips. The aim is to make it easier for the infant to take a mouthful of breast tissue, rather than to push the nipple into their mouth. 4. Invite a wide mouth. Allow the infant to open their mouth widely before bringing them onto the breast. Their chin should make contact first, with the nipple directed towards the nose. This supports a chin-first approach to attachment. 5. Support the attachment. As the infant comes onto the breast, maintain the shape and support needed to help them take a comfortable, deep mouthful. A flipple technique may also be helpful for some feeding dyads. These approaches are discussed further in Breastfeeding: latch and positioning. 6. Settle into a comfortable position. Once the latch feels sustainable, the infant has established a secure seal and feeding is comfortable, allow yourself to relax your shoulders and arms. You can continue to support or hold the breast if this remains helpful; there is no need to remove your hand if doing so changes the infant's attachment. Breast shaping should feel comfortable. It should not involve pulling the breast towards the infant, squeezing painfully or forcing the infant to attach. Breast compression Breast compression involves applying gentle pressure to the breast while an infant is feeding. This can encourage milk flow and help maintain milk transfer when an infant's sucking becomes less effective (Newman, 2017; Pearson-Glaze, 2023). An infant may continue to suck without transferring much milk. Watching for swallowing, rather than relying on sucking movements alone, helps identify when milk is being transferred. Newman (2017) describes breast compression as a way of encouraging milk flow when an infant is sucking but is no longer drinking actively. Recognising the signs of swallowing can help families understand when their baby is actively transferring milk during a feed. See Recognising Infant Swallowing During Feeds for more information about what to look for. Why breast compression may help Breast compression can encourage milk flow and may help an infant take more milk during a feed. It can be useful when swallowing slows, when an infant is sleepy or less active at the breast, or when there are concerns about milk transfer and weight gain (Newman, 2017; Pearson-Glaze, 2023). Milk production is influenced by how frequently and effectively milk is removed from the breast. If breast compression helps an infant remove more milk, it may contribute to supporting milk production. However, breast compression alone cannot guarantee an increase in supply or weight gain. Feeding frequency, attachment, infant feeding ability and other factors also need to be considered (Daly and Hartmann, 1995; Pados and Camp, 2024). How to use breast compression 1. Start with the infant attached. Allow the infant to attach and begin feeding. Observe their sucking and swallowing pattern. 2. Look for active milk transfer. When milk is flowing, you may see a pattern of sucking followed by a pause as the infant swallows. As swallowing slows or stops, the infant may continue sucking without taking much milk. 3. Apply comfortable pressure. Gently compress the breast while the infant is sucking but not swallowing effectively. Maintain the pressure while the infant is drinking, rather than repeatedly squeezing in time with every suck. 4. Release when swallowing slows or stops. Allow the infant to continue sucking and see whether active swallowing starts again. If it does, you can apply breast compression again when swallowing slows. 5. Adjust your hand position. You can move your hand to a different area of the breast if needed. Continue to use comfortable pressure and respond to the infant's feeding pattern. 6. Offer the other breast when appropriate. When the infant is no longer drinking actively from the first breast, you can offer the other side. Breast compression can be used there too, if it is helpful. The amount of support needed varies. Some infants may need breast compression for only part of a feed, while others may benefit from it for much of the feed. Follow the infant's cues and allow them to pause, come off the breast or finish feeding when they are ready (Newman, 2017). Two ways to apply breast compression There is more than one way to position the hand when applying breast compression. The most important considerations are that the pressure is comfortable, the infant can remain attached and milk transfer is encouraged. Flat-hand breast compression Place the flat of your hand against the breast and apply gentle, broad pressure. This can be useful when a wider area of the breast needs support. Adjust the position of your hand as needed, while keeping pressure comfortable. Breast compression using a C-shaped hold Place your thumb on one side of the breast and your fingers on the other, forming a C shape. Apply gentle pressure between the thumb and fingers. This hand position can also be used for breast shaping, so the two techniques can overlap. The hand can be repositioned to find an area where breast compression encourages milk flow without discomfort. The video demonstration by Jack Newman shows how breast compression can be used during a feed: Breast compression – Jack Newman. Breast contact and pressure There is no need to avoid touching or supporting the breast during feeding. Comfortable breast shaping and responsive breast compression are practical ways of supporting attachment and milk transfer. This is different from applying excessive or uncomfortable pressure to one area of the breast for prolonged periods. The aim is to use pressure in response to the infant's feeding, adjusting or releasing it as needed. Research and clinical discussion about breast inflammation have considered sustained external pressure as one possible factor, but this should not be confused with ordinary, comfortable hand support during a feed (Douglas, 2022; Pearson-Glaze, 2023). Using breast shaping and breast compression together Breast shaping and breast compression can be used together. For example, a caregiver may first shape the breast to help the infant attach, then maintain a supportive hand position and use breast compression when swallowing slows. A C-shaped hold can be particularly useful for this because the same hand position can support the breast's shape and apply pressure during feeding. The purpose of the hand movement changes according to what the infant needs at that point in the feed. The aim is to support comfortable attachment and effective milk transfer, not to make the infant continue feeding when they are showing signs that they have finished. When these techniques are not enough Breast shaping and breast compression can be useful tools, but they do not replace an assessment of the whole feeding picture. If an infant is persistently struggling to attach, feeding for long periods without appearing satisfied, having difficulty transferring milk or not gaining weight as expected, further assessment may be needed. Positioning, attachment, oral function, tongue movement, milk supply and the infant's ability to coordinate sucking, swallowing and breathing may all be relevant. A review of the infant's feeding can help identify whether changes to positioning, additional feeding support or assessment of oral function are appropriate. You may find these articles helpful: Breastfeeding: latch and positioning A guide to understanding your baby's oral function When to seek feeding support If you are concerned about your infant's milk intake, weight gain, feeding behaviour or your milk production, seek support from an appropriately qualified infant feeding practitioner or healthcare professional. An assessment can help establish whether the difficulty relates to attachment, milk transfer, infant oral function, milk supply or another factor. You can read more about the different types of feeding support available in these articles: What does an infant feeding specialist do? What is an IBCLC? Feeding support explained When can a lactation consultant support you? References Daly, S.E.J. and Hartmann, P.E. (1995) ‘Infant demand and milk supply. Part 2: The short-term control of milk synthesis in lactating women’, Journal of Human Lactation, 11(1), pp. 27–37. https://doi.org/10.1177/089033449501100120 Douglas, P. (2022) ‘Re-thinking benign inflammation of the lactating breast: classification, prevention, and management’, Women's Health, 18. Douglas, P. and Keogh, R. (2017) ‘Gestalt breastfeeding: Helping mothers and infants optimize positional stability and intraoral breast tissue volume for effective, pain-free milk transfer’, Journal of Human Lactation, 33(3), pp. 509–518. https://doi.org/10.1177/0890334417707958 Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. https://doi.org/10.1016/j.earlhumdev.2007.12.008 Geddes, D.T., Langton, D.B., Gollow, I., Jacobs, L.A., Hartmann, P.E. and Simmer, K. (2008) ‘Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal and sucking mechanism as imaged by ultrasound’, Pediatrics, 122(1), pp. e188–e194. https://doi.org/10.1542/peds.2007-2553 Newman, J. (2017) ‘Breast compression’, International Breastfeeding Centre, 23 May 2017. https://ibconline.ca/breastcompression/ Pados, B.F. and Camp, L. (2024) ‘Physiology of human lactation and strategies to support milk supply for breastfeeding’, Nursing for Women's Health, 28(4), pp. 303–314. https://doi.org/10.1016/j.nwh.2024.01.007 Pearson-Glaze, P. (2023) ‘What is breast compression?’, Breastfeeding Support, revised 9 October 2023. https://breastfeeding.support/what-is-breast-compression/ Smyth, C. (2017) ‘Breast shaping – it is ok to hold your breast!’, 22 October 2017. https://www.carolsmyth.co.uk/perinatal-infant/breastfeeding-resources/posts/2017/october/breast-shaping/ Smyth, C. (2020) ‘Baby to breast not breast to baby’, 23 February 2020. https://www.carolsmyth.co.uk/perinatal-infant/breastfeeding-resources/posts/2020/february/baby-to-breast-not-breast-to-baby/

Candida is a yeast that can be present naturally on the skin and in the mouth, gut and other parts of the body without causing infection. An overgrowth can cause candidiasis, more commonly known as thrush. Candida can cause oral thrush in babies. However, the diagnosis of Candida infection affecting the nipple or breast during breastfeeding is less straightforward. Nipple pain, burning sensations and pain radiating into the breast have often been attributed to Candida, sometimes leading to antifungal treatment for both the breastfeeding parent and baby. Current evidence questions whether Candida is responsible for many of these symptoms. A review by Douglas (2021) found that the evidence linking Candida detected in breast milk or on the nipple to breastfeeding pain is inconsistent. Candida may be detected in people who have no symptoms, and the presence of the organism does not, by itself, establish that it is causing an infection. The review also highlighted the risk of overlooking other explanations for pain and using antifungal treatment when it may not be appropriate. The UNICEF UK Baby Friendly Initiative's updated information sheet on Candida (2025) similarly highlights the need to reconsider the routine diagnosis of nipple thrush and the assumption that Candida is commonly passed between breastfeeding parents and babies. It recommends skilled assessment of breastfeeding and consideration of other causes of pain before antifungal treatment is started. This does not mean that Candida infection cannot occur. It means that symptoms such as burning nipple pain, shiny skin or breast pain between feeds should not automatically be diagnosed as thrush. Candida testing and diagnosis Testing may be considered where Candida infection is suspected, but a positive result does not necessarily establish an active infection or explain the symptoms being experienced. Candida can be present without causing disease. Its detection needs to be interpreted alongside the clinical presentation and assessment findings. A positive test should not be used in isolation to justify antifungal treatment, particularly where other possible causes of nipple or breast pain have not been explored. Testing may involve a sample from the nipple or affected skin, or a breast milk sample. A swab or other sample may detect Candida, but this does not prove that it is responsible for pain or that the breastfeeding parent has an active infection. The same consideration applies to breast milk testing: detection of Candida in a milk sample does not establish that it is causing symptoms or that the baby has an infection. Testing may be appropriate in selected circumstances, particularly where the diagnosis is uncertain, symptoms persist or treatment has not been effective. It is not a routine requirement for every breastfeeding parent experiencing nipple pain. Other causes of nipple and breast pain Persistent nipple or breast pain deserves a thorough assessment. Treating presumed thrush without identifying the cause may delay appropriate support and expose the breastfeeding parent or baby to medication that may not be needed. The Breastfeeding Network reviewed its approach to persistent breast and nipple pain in November 2024. It withdrew its previous thrush factsheets while reassessing the evidence and now encourages families and healthcare professionals to consider other possible causes of pain and prioritise skilled breastfeeding support. The following are some of the causes that may need to be considered. Positioning and attachment Ineffective positioning and attachment are common contributors to nipple pain. If a baby attaches shallowly or compresses the nipple during feeding, repeated friction and pressure can cause soreness, damage, cracking or bleeding. The appearance of the nipple after a feed can provide useful information. A nipple that appears flattened, ridged or lipstick-shaped may indicate compression. Persistent pain, rather than brief initial sensitivity that settles quickly, warrants further assessment. An observed feed can help identify whether the baby's position, attachment, oral function or milk transfer may be contributing. Changes to positioning and attachment may improve comfort, but persistent pain or nipple damage needs further investigation. Further reading: Breastfeeding latch and positioning How to improve infant latch: practical breastfeeding support Painful breastfeeding latch: support that helps Signs of poor milk transfer in your baby at feeds Hand expressing and breast pump expressing Expressing milk should not cause ongoing pain or damage. Hand expression can become uncomfortable if the nipple is pinched, pulled or compressed rather than pressure being applied behind the nipple to move milk forwards. With a breast pump, discomfort may be associated with an unsuitable flange size or shape, excessive suction, friction or the position of the nipple within the flange. A flange that is too small or too large can contribute to rubbing, swelling and nipple trauma. Pain should not be treated as an inevitable part of expressing. The equipment, flange fit, suction setting and expressing technique may all need to be reviewed. Further reading: How to express breast milk Breast pump flange fitting: size, shape, comfort and milk removal Dermatitis, eczema and psoriasis Skin conditions can affect the nipple and areola and may cause itching, redness, soreness, scaling, cracking or weeping. Eczema, irritant or allergic contact dermatitis and psoriasis are among the possible causes. Repeated exposure to moisture, friction, breast pads, laundry products, soaps, creams or other topical products may aggravate sensitive skin. The appearance can vary, and changes may be harder to recognise on darker skin tones. Where a skin condition is suspected, assessment should consider the wider pattern of symptoms, any history of skin problems and possible irritants or allergens. Persistent, unusual or one-sided nipple changes should be assessed by a healthcare professional rather than assumed to be a breastfeeding-related infection. Nipple vasospasm and Raynaud's phenomenon Vasospasm occurs when the blood vessels supplying the nipple temporarily narrow, reducing blood flow. It may cause sharp, burning or throbbing pain during or after a feed, and can also occur between feeds. A nipple may change colour as blood flow alters. It may become white, then blue or purple, before returning to its usual colour. These changes are not always visible, particularly on darker skin tones. Vasospasm can be triggered by cold and may occur after nipple compression or trauma during feeding. Improving positioning and attachment may help where compression is contributing, but persistent symptoms may need further assessment. Further reading: Raynaud's phenomenon and nipple vasospasm pain Neuropathic pain (nerve pain) Neuropathic pain is pain caused by irritation or dysfunction of the nerves involved in sensation. It may be described as burning, shooting, electric-shock-like, tingling or stabbing pain. It can occur during feeding, afterwards or between feeds. The description of pain alone does not establish a neuropathic diagnosis. Other causes, including nipple trauma, vasospasm, skin conditions and breast inflammation, need to be considered. Persistent pain may require assessment by a healthcare professional with appropriate expertise. SSRIs Selective serotonin reuptake inhibitors (SSRIs) are medicines commonly prescribed for depression and anxiety. Their potential relationship with persistent nipple or breast pain has been discussed in clinical case discussions, including work presented by Naomi Dow. This is an area where the evidence is limited. A possible association should not be interpreted as proof that an SSRI is causing pain, and prescribed medication should not be stopped or changed without advice from the prescribing clinician. Where pain begins or changes after starting a medicine or altering a dose, this information can be included in the clinical assessment. Bacterial infection, breast inflammation and the breast microbiome Not all breast inflammation is caused by bacteria, and not every cracked or sore nipple is infected. It is important to distinguish local skin infection from inflammation within the breast, and to recognise when further medical assessment is needed. Infected nipple wounds Cracks, fissures and other breaks in the nipple skin can provide an entry point for bacteria. Staphylococcus aureus is one organism that has been identified in infected sore nipple wounds. However, a damaged nipple is not automatically infected. Pain and cracking can arise from mechanical trauma, including repeated compression or friction during feeding or expressing. A wound that is increasingly painful, inflamed, weeping, crusted or producing pus needs clinical assessment. Where bacterial infection is suspected, a healthcare professional may consider a swab and appropriate treatment. The choice of treatment depends on the appearance and extent of the infection, the clinical assessment and any relevant test results. Persistent or worsening symptoms should not be managed solely by changing feeding technique or applying topical products without assessment (Livingstone and Stringer, 1999). Impetigo Impetigo is a contagious bacterial skin infection. It commonly affects the face and hands but can occur on other areas of skin, including around the nipple. It may begin as red sores or blisters that break down and develop golden or honey-coloured crusts. Impetigo can spread through direct contact with infected skin or contaminated items, so advice about hygiene and treatment is important. A suspected infection around the nipple should be assessed so that appropriate treatment can be selected. The NHS advises that impetigo usually affects skin that is already damaged, such as through a cut, scratch or an existing skin condition (NHS, 2024). Mastitis: inflammation and bacterial infection Mastitis describes inflammation of the breast. It is most common during breastfeeding, but it can also occur in people who are not breastfeeding. Breast inflammation may involve swelling, tenderness, warmth and pain, sometimes accompanied by a firm or swollen area. Some people also experience flu-like symptoms, including aches, chills or a raised temperature. Mastitis is not always caused by a bacterial infection. Inflammation can develop when milk is not being removed effectively or when there is localised swelling and narrowing within the breast. Bacterial mastitis is a possible progression, but the two terms should not be used interchangeably. The Academy of Breastfeeding Medicine's Clinical Protocol #36 describes mastitis as a spectrum that includes ductal narrowing, inflammatory mastitis, bacterial mastitis, phlegmon and abscess (Mitchell et al., 2022). This helps explain why not every episode of breast inflammation requires antibiotics. Assessment is important where symptoms are severe, worsening or not improving. Antibiotics may be required when bacterial mastitis is diagnosed or suspected. Families should seek medical advice if symptoms are not improving within 12 to 24 hours of appropriate self-care, or sooner if they feel very unwell. The NHS advises continuing to breastfeed if possible and avoiding excessive pumping or firm breast massage (NHS, Mastitis). Further reading: Reverse pressure softening technique for engorgement Breast abscess A breast abscess is a collection of pus within the breast tissue. It can develop as a complication of mastitis and may present as a painful, swollen or warm area, sometimes with a persistent lump. A person may also feel generally unwell. An abscess needs medical assessment. Ultrasound may be used to identify the collection, and treatment commonly involves draining the pus. Antibiotics may also be needed. Breastfeeding or expressing can often continue during treatment, but the plan depends on the location of the abscess, the procedure used and the individual's circumstances. A healthcare professional should advise on feeding from the affected breast and any wound-care precautions. A persistent or worsening lump should not be assumed to be a blocked duct or uncomplicated mastitis. It needs assessment to establish the cause. The breast microbiome and dysbiosis The breast has a microbiome: a community of microorganisms that may include bacteria and other organisms. Research into the breast microbiome and how it may relate to breastfeeding, inflammation and pain is continuing. The term dysbiosis is used to describe a change or imbalance in a microbial community. It is not, by itself, a diagnosis of bacterial infection. Detecting particular organisms, or identifying differences between microbial communities, does not automatically establish that they are causing symptoms or that antimicrobial treatment is needed. Research into the breast microbiome is still developing. The presence of bacteria in breast milk should not be interpreted as evidence that milk is contaminated or that the breastfeeding parent has an infection. Clinical findings and the person's symptoms remain important when deciding whether investigation or treatment is appropriate (Douglas, 2021). Oral thrush in babies Oral thrush is a recognised Candida infection in babies. It commonly presents as creamy white patches, known as plaques, inside the mouth. These may appear on the tongue, gums, inside the cheeks or the roof of the mouth. The affected areas can become sore and feeding may be uncomfortable (Kingston and Richmond NHS Foundation Trust, 2024; UNICEF UK Baby Friendly Initiative, 2025). Milk residue and a coated tongue A white coating on a baby's tongue is not necessarily oral thrush. Milk residue can collect on the surface of the tongue, around the filiform papillae (the small projections that give the tongue its textured appearance). The tongue's movement against the palate during feeding helps to clear material from its surface. Where tongue elevation is restricted, this natural cleaning action may be less effective and a coating may be more noticeable. This may be one explanation for a persistent white coating on the tongue, although it is not, by itself, evidence of tongue-tie or a Candida infection. Milk residue is more likely to be confined to the tongue, whereas oral thrush can also affect the gums, inside of the cheeks and roof of the mouth. Thrush plaques are not usually removed by gently wiping with a clean cloth. They should not be scraped or forcibly removed. Where there is uncertainty, or the baby has feeding difficulties, discomfort or other symptoms, clinical assessment is appropriate (Kingston and Richmond NHS Foundation Trust, 2024; UNICEF UK Baby Friendly Initiative, 2025). Signs and symptoms Oral thrush may cause no obvious discomfort, particularly when the infection is mild. Some babies may show: Creamy white plaques on the tongue, gums, inside of the cheeks or roof of the mouth. Soreness or discomfort around the mouth. Unsettled behaviour during feeds. Reluctance to feed or difficulty maintaining their usual feeding pattern. A white film on the lips. Some babies with oral thrush also have a persistent nappy rash associated with Candida. However, the presence of one symptom does not, by itself, establish the other. Each area needs to be assessed in its own right (Kingston and Richmond NHS Foundation Trust, 2024; NHS, Thrush – breastfeeding). If a baby is feeding less than usual, it is important to consider their overall milk intake, hydration and weight gain, rather than concentrating only on the appearance of the tongue. A baby who is reluctant to feed, has fewer wet nappies or appears unwell needs prompt assessment. Diagnosis and management Oral thrush is usually diagnosed from the appearance of the mouth and the baby's symptoms. A swab is not routinely required for an uncomplicated presentation, although a healthcare professional may consider one if the diagnosis is uncertain or symptoms are persistent or recurrent. Mild cases may resolve without treatment. Where treatment is needed, an antifungal medicine may be prescribed or supplied following an appropriate assessment. Miconazole oral gel is used to treat oral candidiasis. The product information specifies that it is suitable for infants aged four months and older, provided their swallowing reflex is sufficiently developed. The dose for infants is divided into smaller portions and applied to the affected areas with a clean finger. It must not be placed at the back of the throat because of the risk of choking. The manufacturer's product information also highlights that swallowing development varies between infants. The lower age limit should be increased to five or six months for infants who were born prematurely or who have slow neuromuscular development. The baby's gestation, development and individual circumstances therefore need to be considered before the medicine is supplied or used (McNeil Products Ltd, 2026). It is important to distinguish between the two UK miconazole oral gel products. Daktarin Sugar Free 2% Oral Gel is available as a Pharmacy medicine, whereas standard Daktarin Oral Gel is a Prescription Only Medicine. The product classification does not remove the need for an appropriate assessment. A pharmacist must consider whether supply is suitable, including the baby's age, swallowing development and any relevant precautions. Nystatin oral suspension is another antifungal treatment that may be prescribed where clinically appropriate. Families should follow the instructions supplied with the specific product and the advice of the prescribing or supplying healthcare professional. Medicines should not be applied to the nipple for the baby to suck from unless specifically advised by an appropriate prescriber. Breastfeeding can generally continue while a baby is being treated for oral thrush. If feeding is too uncomfortable for the breastfeeding parent or baby, expressing may help maintain milk removal while further support is arranged. Expressed breast milk during treatment Families have previously been advised to label milk expressed during a thrush infection and avoid freezing it for later use, because freezing does not reliably kill yeast and there was concern that the milk could cause reinfection. Current NHS breastfeeding guidance states that there is no evidence to suggest that using expressed or stored milk during a thrush infection causes reinfection. It advises that expressed milk can be used while the breastfeeding parent and baby are receiving treatment (NHS, Thrush – breastfeeding). The NHS also has general oral-thrush information that continues to advise against freezing milk for later use, so published guidance is not entirely consistent. Families should not be told to discard expressed milk solely because it was collected during treatment. Milk should still be labelled and dated as part of ordinary breast milk storage practice, and stored in accordance with current guidance (NHS, Storing breast milk). When to seek further support Persistent nipple or breast pain deserves assessment, particularly where it is affecting feeding, expressing, sleep or wellbeing. Increasing redness or swelling, pus, spreading skin changes, fever, flu-like symptoms or a baby who is feeding poorly or becoming unwell should prompt medical advice. A skilled infant feeding assessment can help explore positioning and attachment, milk transfer, expressing technique and possible oral function difficulties. An infant feeding specialist or International Board Certified Lactation Consultant (IBCLC) can support families with breastfeeding challenges and help identify when referral to another healthcare professional is needed. An IBCLC or infant feeding specialist does not replace medical assessment where infection, a skin condition or another medical cause is suspected. Equally, persistent pain should not automatically be attributed to Candida or treated with antifungal medication without considering other explanations. Further information: What does an infant feeding specialist do? What is an IBCLC? Feeding support explained When can a lactation consultant support you? The most useful starting point is a careful assessment of the feeding dyad and the symptoms being experienced. Identifying the cause of pain matters: it helps families access appropriate support and reduces the risk of unnecessary treatment. References Douglas, P. (2021) ‘Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women’, Women's Health, 17, pp. 1–15. doi: 10.1177/17455065211031480. Kingston and Richmond NHS Foundation Trust (2024) Oral thrush in babies. Last updated 9 December 2024. Livingstone, V. and Stringer, L.J. (1999) ‘The treatment of Staphylococcus aureus infected sore nipples: a randomized comparative study’, Journal of Human Lactation, 15(3), pp. 241–246. doi: 10.1177/089033449901500315. McNeil Products Ltd (2026) Daktarin Oral Gel: Summary of Product Characteristics. Last updated 4 September 2026. Available at: https://www.medicines.org.uk/emc/product/14746/smpc Mitchell, K.B. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’, Breastfeeding Medicine, 17(5), pp. 360–376. doi: 10.1089/bfm.2022.29207.kbm. NHS (2024) Impetigo. Page last reviewed 6 June 2024. Available at: https://www.nhs.uk/conditions/impetigo/ NHS (date not displayed) Mastitis. NHS website. Available at: https://www.nhs.uk/conditions/mastitis/ NHS (date not displayed) Storing breast milk. NHS website. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/expressing-breast-milk/ NHS (date not displayed) Thrush – breastfeeding. NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/breastfeeding-challenges/thrush/ UNICEF UK Baby Friendly Initiative (2025) Information sheet on Candida (thrush). April 2025. Available at: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2025/04/Infosheet-on-thrush.pdf

Thyroid conditions are relatively common, including during pregnancy and the postnatal period. Thyroid hormones have an important role in the body, including metabolism, energy regulation, pregnancy and lactation. Most people with a thyroid condition can breastfeed. A diagnosis does not automatically mean that breastfeeding will be difficult or that breastmilk production will be affected. However, some thyroid conditions can influence maternal health, milk production or, in particular circumstances, a baby's thyroid function after birth. Understanding the differences between thyroid conditions, recognising when further assessment may be needed and knowing how treatment fits alongside breastfeeding can help families access appropriate support. Thyroid function and breastfeeding The thyroid gland produces hormones that help regulate metabolism and influence the function of many body systems. Thyroid hormones also have a role in reproductive health, pregnancy and the physiological changes involved in establishing lactation. During pregnancy, thyroid hormone requirements change. After birth, the body undergoes further hormonal adjustments as lactation becomes established. A thyroid condition that is untreated, inadequately controlled or develops during the postnatal period may therefore be relevant to maternal wellbeing and breastfeeding. The effect varies according to the underlying condition, its severity and whether thyroid hormone levels are adequately managed. Common thyroid conditions Hypothyroidism and Hashimoto’s thyroiditis Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormone. Hashimoto’s thyroiditis is an autoimmune condition and a common cause of hypothyroidism. Symptoms can include fatigue, feeling cold, constipation, dry skin, difficulty concentrating and low mood. Some symptoms overlap with the physical and emotional changes associated with pregnancy and caring for a newborn, which can make a thyroid condition harder to recognise. Untreated or inadequately treated hypothyroidism may affect general health and has been associated with difficulties establishing or maintaining milk production. Appropriate treatment and monitoring are important, including after birth when thyroid hormone requirements may change. Graves’ disease and hyperthyroidism Hyperthyroidism occurs when the thyroid gland produces excessive thyroid hormone. Graves’ disease is an autoimmune condition and an important cause of hyperthyroidism. Symptoms may include palpitations, a racing heartbeat, anxiety, tremor, heat intolerance, sweating, weight loss and difficulty sleeping. These symptoms can be distressing and may overlap with experiences during the postnatal period. Graves’ disease is particularly relevant to newborn health because thyroid-stimulating receptor antibodies (TRAb) can cross the placenta and affect the baby's thyroid gland. This can happen even if the birthing parent has previously received treatment for Graves’ disease, including thyroid surgery or radioactive iodine, and no longer has an overactive thyroid. Postpartum thyroiditis Postpartum thyroiditis is an inflammation of the thyroid gland that develops during the first year after birth. It is thought to be an autoimmune process and can occur in people who have no previous diagnosis of thyroid disease. It may involve an initial phase of excessive thyroid hormone release, followed by a period of reduced thyroid hormone production. Not everyone experiences both phases, and some people develop only one. Postpartum thyroiditis is particularly important because its symptoms can be mistaken for the physical and emotional demands of caring for a newborn. Symptoms may include anxiety, irritability, palpitations, fatigue, low mood, difficulty concentrating and changes in weight. The hypothyroid phase can also contribute to low energy and feeling overwhelmed. Changes in mood, anxiety or emotional wellbeing should not automatically be attributed to thyroid dysfunction. Equally, these experiences should not be dismissed as simply part of new parenthood. Anyone struggling with their mental health should be encouraged to seek support from their GP, midwife or health visitor. Thyroid function testing may be appropriate where symptoms suggest a possible thyroid problem. Breastfeeding aversion can also occur for a range of reasons and may be particularly difficult to manage alongside postnatal exhaustion or changes in wellbeing. Breastfeeding aversion: help and what can make it easier. Understanding the differences | Condition | What happens | Potential relevance after birth | |---|---|---| | Postpartum thyroiditis | Inflammation causes stored thyroid hormone to be released, sometimes followed by reduced hormone production. | Can affect maternal wellbeing and may require monitoring or treatment. | | Graves’ disease | Autoantibodies stimulate the thyroid gland to produce excessive thyroid hormone. | Maternal antibodies can cross the placenta and cause neonatal thyroid dysfunction. | | Thyroid storm (thyrotoxic crisis) | A rare, life-threatening deterioration associated with severe thyrotoxicosis. | A medical emergency requiring urgent hospital treatment. | Adapted from Korevaar et al. (2026), RCOG (2025) and Taylor et al. (2026). Thyroid storm: a medical emergency Thyroid storm, also known as thyrotoxic crisis, is a rare but life-threatening complication of severe hyperthyroidism. It involves an acute deterioration in several body systems and requires emergency hospital treatment. Symptoms may include a very high temperature, marked tachycardia, agitation or confusion, vomiting, diarrhoea, dehydration and cardiovascular complications. It is not simply an episode of anxiety, palpitations or feeling unwell. Although rare, thyroid storm is a medical emergency. Anyone experiencing symptoms suggestive of severe thyrotoxicosis with significant deterioration should seek emergency medical attention (Taylor et al., 2026). Medication and breastfeeding Thyroid conditions may require prescribed medication to regulate thyroid hormone levels or manage symptoms. The choice of treatment will depend on the specific condition, its severity and individual circumstances. Your GP or endocrinologist will advise on appropriate treatment, including whether any changes are needed following pregnancy. Medication doses are guided by thyroid function blood results and clinical assessment. Requirements can change over time, particularly during pregnancy and after birth. Do not adjust, reduce or increase your dose, or stop taking prescribed medication, without first discussing this with your healthcare professional. Many medicines used to manage thyroid conditions are compatible with breastfeeding. However, this depends on the medication and treatment being prescribed, so discuss any concerns with your healthcare professional rather than stopping or changing medication yourself. If you are breastfeeding, chestfeeding or expressing milk, make sure your prescriber knows so that this can be considered when treatment is selected. Non-pharmaceutical remedies, including herbal preparations and supplements marketed for thyroid support, are not a substitute for medical assessment and prescribed treatment. There is insufficient evidence that these products can effectively treat thyroid dysfunction, and some may interfere with thyroid function or prescribed medication. Supplements containing iodine or kelp require particular caution because excessive iodine intake can adversely affect thyroid function. Discuss any supplements or complementary treatments with your healthcare professional before starting them (NICE, 2019, updated 2023; NHS, 2025). Thyroid function and milk production Thyroid hormones play an important role in normal mammary gland development and lactation. They interact with other hormones involved in milk production and influence the metabolic processes required to establish and maintain lactation. Adequate thyroid hormone levels are therefore part of the physiological conditions needed for normal lactation. Research has identified an association between hypothyroidism and difficulties with milk production, and some reports describe improvement following appropriate thyroid hormone replacement. However, much of the available human evidence is limited, and the relationship between thyroid dysfunction, milk production and breastfeeding duration is not yet fully understood. The 2026 American Thyroid Association guideline acknowledges this uncertainty and concludes that clinically significant effects are unlikely in most cases (Alexander et al., 2017; Korevaar et al., 2026). The evidence relating to excessive thyroid hormone levels and milk production is also limited. It is therefore important not to assume that all thyroid conditions have the same effect on lactation. Thyroid function should be considered when investigating unexplained low milk production or difficulties establishing lactation, alongside other potential physiological and feeding-related factors. A thyroid condition should not automatically be assumed to be the cause, but neither should its potential contribution be overlooked. An International Board Certified Lactation Consultant (IBCLC) can help assess the feeding dyad, including milk transfer, feeding effectiveness, milk production and the practicalities of breastfeeding or expressing. This assessment can help identify feeding-related factors and establish whether further medical investigation may be appropriate. An IBCLC does not replace medical assessment or treatment of thyroid conditions. For further information, see What is an IBCLC? Feeding support explained, Breastfeeding latch and positioning and How to express breastmilk. Thyroid testing after birth People with a known thyroid condition may need further blood tests after birth to check thyroid hormone levels and review whether their treatment remains appropriate. Thyroid hormone requirements can change during pregnancy and after delivery, so medication doses may need to be reviewed. The timing and frequency of testing depend on the underlying condition, treatment and individual circumstances. Your GP or endocrinology team can advise on the monitoring needed (NICE, 2019, updated 2023; RCOG, 2025). For example, RCOG advises that thyroid blood tests should be checked around six weeks after birth to review treatment. People with Graves’ disease or other forms of hyperthyroidism may also need postnatal monitoring. The appropriate plan will depend on their individual circumstances. Postpartum thyroiditis can also develop in people without a previous thyroid diagnosis. Symptoms may initially be attributed to tiredness, anxiety or the demands of caring for a newborn. Where symptoms are persistent, unexplained or concerning, a GP can assess whether thyroid function testing is appropriate. The 2026 American Thyroid Association guideline recognises that the relationship between thyroid function and lactation difficulties is not fully established. There is insufficient evidence to recommend routine thyroid screening or treatment solely to improve milk production. This does not mean that thyroid function should be overlooked where there are other symptoms, a known thyroid condition or clinical reasons to investigate it (Korevaar et al., 2026). When a baby needs additional thyroid monitoring Most babies born to people with thyroid conditions do not develop thyroid problems. However, certain maternal conditions, antibodies and treatments during pregnancy can place a baby at increased risk. This is particularly important where the birthing parent: Has current or previous Graves’ disease, including where the thyroid gland has been surgically removed or treated with radioactive iodine. Has raised thyroid-stimulating receptor antibodies (TRAb). Has taken antithyroid medication, such as carbimazole or propylthiouracil (PTU), during pregnancy. TRAb antibodies can cross the placenta and stimulate the baby's thyroid gland. Antithyroid medication can also cross the placenta and temporarily suppress the baby's thyroid function. These effects can occur together, meaning that a baby may initially appear well before developing signs of thyroid dysfunction. A baby's risk depends on the maternal history, antibody levels and treatment during pregnancy. The neonatal or paediatric team should be informed of relevant thyroid history so that appropriate assessment and monitoring can be arranged. Where indicated, thyroid blood tests may be taken shortly after birth and repeated at around one to two weeks of age. The timing and need for further testing will be determined by the baby's clinical team (RCOG, 2025; van der Kaay et al., 2016). Not every maternal thyroid condition requires additional neonatal testing. For example, uncomplicated hypothyroidism without relevant antibodies or antithyroid medication exposure does not automatically mean that a baby needs extra thyroid monitoring. Signs of thyroid problems in newborn babies Neonatal hyperthyroidism can cause symptoms that may not be obvious immediately after birth. Symptoms can develop over the first few weeks as the effects of maternal antithyroid medication reduce while stimulating antibodies remain active. Possible signs include: Difficulty feeding or poor weight gain despite an increased appetite. Irritability, restlessness, jitteriness or difficulty sleeping. A persistently fast heartbeat or abnormal heart rhythm. Excessive sweating, flushing or heat intolerance. Vomiting or diarrhoea. Breathing difficulties. An enlarged thyroid gland (goitre). Prominent or staring eyes. Jaundice or other signs of systemic illness. Not all babies will show the same symptoms, and some may have no obvious signs initially. A baby with a relevant maternal history should receive the recommended monitoring even if they appear well. Any concerns about a newborn's feeding, behaviour, breathing, heart rate or general condition should be discussed promptly with a healthcare professional. Severe breathing difficulties, marked lethargy or significant deterioration require emergency assessment (Endotext, 2019; van der Kaay et al., 2016). Congenital hypothyroidism and newborn screening Congenital hypothyroidism is a condition in which a baby is born with insufficient thyroid hormone production. Thyroid hormones are essential for normal growth and brain development, so early identification and treatment are important. In the UK, congenital hypothyroidism is included in the NHS newborn blood spot screening programme. The heel-prick test is usually offered when a baby is around five days old. The screening laboratory measures thyroid-stimulating hormone (TSH) in the blood spot sample to help identify babies who may have congenital hypothyroidism. Where a screening result suggests possible congenital hypothyroidism, further testing and treatment are arranged (NHS, 2025; NHS England, 2024). Routine newborn screening does not replace additional thyroid testing where a baby is considered at risk because of maternal Graves’ disease, raised TRAb antibodies or antithyroid medication exposure during pregnancy. These are separate clinical considerations and may require a different monitoring pathway. Considerations for infant procedures A known or suspected thyroid condition in a baby is relevant to decisions about elective procedures, including frenulotomy. Thyroid dysfunction can affect heart rate, metabolism and general physiological stability. Where a baby has suspected or confirmed neonatal thyroid dysfunction, the priority is paediatric assessment and medical management before an elective procedure is considered. An infant with suspected or confirmed neonatal thyroid dysfunction should not undergo elective tongue-tie release in a non-hospital setting; paediatric assessment and medical stabilisation are required before any decision about the procedure and its appropriate setting is made. The appropriate timing and setting for any procedure should be determined following assessment by the relevant medical team, taking account of the baby's clinical condition and any associated risks (RCoA, 2025). Joined-up care Thyroid conditions do not automatically prevent breastfeeding. Many people with thyroid disorders breastfeed successfully with appropriate assessment, treatment and support. When feeding difficulties or low milk production occur, it is important to consider the whole feeding picture rather than assuming that thyroid dysfunction is the cause. Milk production, milk transfer and the effectiveness of feeding are related, but they are not the same thing. Where milk production is lower than expected, assessment may need to consider thyroid function alongside other maternal health factors, milk removal, feeding frequency and the effectiveness of milk transfer. My article Protecting breast milk supply when feeding is inefficient explains why ineffective milk removal can affect ongoing production and why protecting supply may need to be considered while feeding difficulties are being investigated. Families should not have to work through persistent feeding difficulties alone. An appropriately qualified infant-feeding professional can help assess the feeding dyad, including positioning, attachment, sucking, swallowing, milk transfer, feeding effectiveness and milk production. This can help identify where practical feeding support may be useful and whether further medical assessment or referral is needed. An International Board Certified Lactation Consultant (IBCLC) has specialist knowledge of lactation and breastfeeding and can support families with concerns about milk production, milk transfer, feeding difficulties and expressing. Other infant-feeding professionals, including midwives, health visitors and specialist feeding teams, may also have an important role depending on the family's needs. You can read more about what an infant-feeding specialist does, what an IBCLC is and how they support infant feeding, and when a lactation consultant can support you. Medical assessment remains important where thyroid dysfunction is suspected or a known condition needs monitoring. An IBCLC or other feeding specialist does not replace GP or endocrinology care, but can help ensure that feeding needs are recognised and supported alongside medical treatment. Joined-up care means considering both the health of the person breastfeeding and the needs of the baby, without overlooking either the possible medical contributors or the practical support that can make feeding more manageable. References Alexander, E.K. et al. (2017) ‘2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum’, Thyroid, 27(3), pp. 315–389. doi: 10.1089/thy.2016.0457. Chan, S. et al. (2025) ‘Management of thyroid disorders in pregnancy’, BJOG, 132(8), pp. e130–e161. doi: 10.1111/1471-0528.18088. Drugs and Lactation Database (LactMed®) (2026) ‘Levothyroxine’. Last revised 15 October 2026. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501003/. Endotext (2019) ‘Neonatal hyperthyroidism’. Available at: https://www.ncbi.nlm.nih.gov/books/. Korevaar, T.I.M. et al. (2026) ‘American Thyroid Association 2026 Guidelines for Thyroid Disease in Preconception, Pregnancy, and Postpartum’, Thyroid, 36(5), pp. 481–544. doi: 10.1177/10507256261445624. National Institute for Health and Care Excellence (NICE) (2019, updated 2023) Thyroid disease: assessment and management. NICE guideline NG145. Available at: https://www.nice.org.uk/guidance/ng145. NHS (2025) ‘Iodine’. Vitamins and minerals. Available at: https://www.nhs.uk/conditions/vitamins-and-minerals/iodine/. NHS (2025) ‘Newborn blood spot test’. Available at: https://www.nhs.uk/baby/newborn-screening/blood-spot-test/. NHS England (2024) Laboratory guide to screening for congenital hypothyroidism in the UK. Available at: https://www.gov.uk/government/publications/congenital-hypothyroidism-screening-laboratory-handbook. NHS Specialist Pharmacy Service (2023) ‘Using beta-blockers during breastfeeding’. Royal College of Anaesthetists (RCoA) (2025) Guidelines for the Provision of Paediatric Anaesthesia Services. Royal College of Obstetricians and Gynaecologists (RCOG) (2025) ‘Thyroid problems in pregnancy’. Available at: https://www.rcog.org.uk/for-the-public/browse-our-patient-information/thyroid-problems-in-pregnancy/. Taylor, P.N. et al. (2026) ‘Management of thyroid emergencies: joint consensus statement on management of thyroid storm’, European Thyroid Journal, 15(4), ETJ260043. doi: 10.1530/ETJ-26-0043. van der Kaay, D.C.M. et al. (2016) ‘Management of neonates born to mothers with Graves’ disease’, Pediatrics, 137(4), e20151878.

Hayfever symptoms can make the warmer months uncomfortable, particularly when sneezing, a runny or blocked nose, and itchy, watery eyes interfere with sleep and everyday activities. If you are breastfeeding, you may also be wondering which treatments are suitable and whether taking medication could affect your baby or your milk supply. In most cases, hayfever can be managed without stopping breastfeeding. There are several non-medicinal measures and treatments that can help, including nasal sprays, antihistamines and eye drops. The choice of treatment matters, but breastfeeding does not automatically mean that you have to put up with symptoms or avoid medication. The Breastfeeding Network provides UK-specific information about managing hayfever while breastfeeding. Its guidance, alongside advice from the NHS Specialist Pharmacy Service (SPS), can help families understand the available options and make informed treatment choices. Reducing pollen exposure Reducing contact with pollen may help ease symptoms, although it is not always possible to avoid it completely. Practical measures include: Checking local pollen forecasts and, where possible, limiting time outdoors when pollen levels are high. Keeping windows and doors closed when pollen levels are high, particularly in the bedroom. Wearing wraparound sunglasses outdoors to reduce pollen reaching the eyes. Changing clothes and washing your face and hands after spending time outside. Showering or washing your hair before going to bed if you have been outdoors for a prolonged period. Avoiding drying clothes and bedding outside when pollen levels are high, as pollen can collect on fabrics. Dusting with a damp cloth to remove pollen that has entered the home. These measures may reduce exposure, but they are not always enough to control symptoms. Treatment may still be needed (NHS, 2026a). Nasal sprays and drops Nasal sprays can be useful for hayfever symptoms, particularly when the nose is affected by inflammation, itching, sneezing or congestion. Intranasal corticosteroid sprays, such as beclometasone, budesonide, fluticasone and mometasone, act locally in the nasal passages to reduce inflammation. They are commonly used to manage allergic rhinitis and can be used while breastfeeding. The NHS Specialist Pharmacy Service advises that topical corticosteroids, including those used intranasally, are compatible with breastfeeding. Because absorption into the mother's bloodstream is generally very low, the amount expected to pass into breast milk is negligible (SPS, 2023). The Breastfeeding Network also explains that nasal sprays act locally and are unlikely to pass into breast milk in significant quantities (The Breastfeeding Network, 2019, amended 2026). Saline nasal sprays or rinses may also help clear pollen and mucus from the nasal passages without using medication. It is important to distinguish corticosteroid sprays from decongestant sprays. Decongestant sprays containing ingredients such as xylometazoline or oxymetazoline are intended to relieve nasal congestion rather than treat the underlying allergic inflammation. The Breastfeeding Network considers these compatible with breastfeeding because they act locally, but they should not be used for more than five consecutive days because prolonged use can cause rebound congestion (The Breastfeeding Network, 2022, amended 2026). Antihistamines Antihistamines help reduce the effects of histamine, a substance released by the immune system during an allergic reaction. They can help relieve symptoms such as sneezing, itching and a runny nose. Non-sedating antihistamines are generally preferred when breastfeeding. Cetirizine and loratadine are the preferred options in the NHS Specialist Pharmacy Service guidance for breastfeeding a healthy, full-term infant (SPS, 2026). Although these medicines are considered suitable, small amounts can pass into breast milk. As a precaution, observe your baby for any unexpected drowsiness, irritability, dry mouth, changes in feeding or inadequate weight gain. Younger, exclusively breastfed babies may be more susceptible to side effects than older infants (SPS, 2026). Sedating antihistamines, such as chlorphenamine, may sometimes be appropriate. However, they are more likely to cause drowsiness in both the person taking them and the baby. If a sedating antihistamine is needed, the SPS identifies chlorphenamine as the preferred option, with occasional doses or short-term use preferable where possible. If you take a medicine that causes drowsiness, consider how this may affect your ability to care for your baby safely. Avoid sharing a bed with your baby after taking sedating medication, as this increases the risk associated with bed-sharing (SPS, 2026). The effect of antihistamines on milk production is not fully established. Available evidence is limited and sometimes conflicting. At normal therapeutic doses, antihistamines are unlikely to affect milk production, particularly once breastfeeding is established. However, occasional reports of reduced supply have been described with some medicines, including cetirizine and loratadine (SPS, 2026). Eye drops Hayfever can cause itchy, red and watery eyes. Eye drops may help relieve these symptoms and can be used alongside other treatments where appropriate. The Breastfeeding Network identifies sodium cromoglicate eye drops as an option during breastfeeding. As eye drops act locally, systemic absorption and transfer into breast milk are expected to be very low (The Breastfeeding Network, 2019, amended 2026). A pharmacist can help identify a suitable product if you are unsure which eye drops to choose. Decongestants and milk supply Some combination cold and hayfever remedies contain oral decongestants, such as pseudoephedrine. These are different from the locally acting nasal sprays discussed above. Oral pseudoephedrine is generally best avoided while breastfeeding because it can reduce milk production. This is particularly relevant if you are establishing breastfeeding or already have concerns about supply. A small study involving eight breastfeeding women found that a single 60 mg dose of pseudoephedrine reduced milk production by an average of 24% over the following 24 hours compared with placebo (Aljazaf et al., 2003). The study was small, so its findings should not be interpreted as meaning that every person taking pseudoephedrine will experience the same reduction. However, the measured effect is clinically relevant, and The Breastfeeding Network advises avoiding oral decongestant tablets, powders and drinks because of their potential impact on milk supply (The Breastfeeding Network, 2022, amended 2026). If you are concerned about your milk production, you may also find it helpful to read Increasing Breast Milk Production, which explores how milk production is regulated and the role of effective milk removal. If you need relief from nasal congestion, a locally acting nasal decongestant spray may be an alternative. These should only be used for a short period and for no longer than five consecutive days. Informed treatment choices You do not need to stop breastfeeding simply because you need treatment for hayfever. The aim is to choose an effective treatment that is appropriate for your symptoms, your circumstances and your baby's age and health. When choosing a medicine, consider: Whether a local treatment, such as a nasal spray or eye drops, could manage the symptoms. Whether a non-sedating antihistamine is appropriate. Whether the product contains additional ingredients, particularly an oral decongestant. Your baby's age, whether they were born prematurely and whether they have any health conditions. Whether breastfeeding is established or you are experiencing difficulties with milk production. Medicines that are suitable for breastfeeding a healthy, full-term infant may need further consideration if your baby was born prematurely, is unwell or has other health needs. The SPS guidance is specifically written for healthy, full-term infants, so individual advice is important in these circumstances (SPS, 2026). A pharmacist, GP or other appropriate healthcare professional can help you choose a suitable treatment. The NHS also advises checking before taking antihistamines or decongestants while breastfeeding. Do not stop prescribed medication without discussing it with the healthcare professional responsible for your care (NHS, 2020). Breastfeeding can continue For most breastfeeding families, hayfever can be managed with appropriate treatment and practical measures to reduce pollen exposure. Nasal corticosteroid sprays, suitable antihistamines and eye drops can all have a place in symptom management. The important point is that breastfeeding does not need to be stopped simply because you have hayfever or need medication. If you are unsure about a particular product, seek advice from a pharmacist, GP or an appropriate medicines-in-breastfeeding service before using it. Can babies get hayfever? Hayfever is less common in babies and very young children than in older children, but it is not impossible. Hayfever, also known as seasonal allergic rhinitis, develops when the immune system becomes sensitised to pollen. This generally involves exposure to pollen over time, which helps explain why it is less commonly seen during infancy. Hayfever usually develops during childhood or adolescence, although it can occur at any age (GOV.UK, 2025). It is more commonly recognised in older children, but younger children can also experience allergic rhinitis. Symptoms may include repeated sneezing, a runny or blocked nose, and red, itchy or watery eyes. However, these symptoms can also occur with viral infections and other forms of nasal irritation. A runny or blocked nose on its own is not enough to identify hayfever. If symptoms are persistent or recurring, or you are concerned that your baby may have an allergy, speak to your GP. They can consider other possible causes and advise whether further assessment is needed (NHS, 2026a; NHS, 2026b). Supporting a baby with hayfever symptoms If pollen exposure appears to make symptoms worse, some practical measures may help reduce the amount of pollen your baby comes into contact with: Keep windows and doors closed when pollen levels are high, where practical. Wash your baby's face and hands after spending time outdoors. Change clothing after being outside and avoid bringing outdoor clothing into the baby's sleeping area. Avoid drying washing outdoors during periods of high pollen. Keep indoor spaces clean, using a damp cloth to remove dust. These measures may help reduce exposure, although they cannot remove pollen completely. Do not give your baby hayfever medication intended for adults or older children. The suitability of antihistamines, nasal sprays and eye drops depends on the child's age, the medicine and the specific product. Some medicines used for older children are not suitable for babies. A GP or pharmacist can advise whether any treatment is appropriate. If symptoms are persistent, troublesome or affecting feeding or sleep, seek advice from a healthcare professional rather than assuming they are caused by hayfever. If your baby has difficulty breathing, significant swelling of the lips, mouth or tongue, or becomes unusually floppy or unresponsive, seek emergency medical help. References Aljazaf, K., Hale, T.W., Ilett, K.F., Hartmann, P.E., Mitoulas, L.R., Kristensen, J.H., Hackett, L.P. and Begg, E.J. (2003) ‘Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk’, British Journal of Clinical Pharmacology, 56(1), pp. 18–24. Available at: https://doi.org/10.1046/j.1365-2125.2003.01822.x. GOV.UK (2025) Hay fever and airborne allergens. Available at: https://www.gov.uk/guidance/hay-fever-and-airborne-allergens. NHS (2020) Breastfeeding and medicines. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding-and-lifestyle/medicines/. NHS (2026a) Allergic rhinitis. Last reviewed 8 January 2026. Available at: https://www.nhs.uk/conditions/allergic-rhinitis/. NHS (2026b) Allergies. Last reviewed 5 March 2026. Available at: https://www.nhs.uk/conditions/allergies/. NHS Specialist Pharmacy Service (SPS) (2023) Using inhaled or topical corticosteroids during breastfeeding. Published 17 July 2023. Available at: https://sps.nhs.uk/articles/using-inhaled-or-topical-corticosteroids-during-breastfeeding/. NHS Specialist Pharmacy Service (SPS) (2026) Using antihistamines during breastfeeding. Last updated 5 February 2026. Available at: https://sps.nhs.uk/articles/using-antihistamines-during-breastfeeding/. The Breastfeeding Network (2019, amended 2026) Hayfever and breastfeeding. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/hayfever/. The Breastfeeding Network (2019, amended 2026) Antihistamines and breastfeeding. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/antihistamines/. The Breastfeeding Network (2022, amended 2026) Decongestants and breastfeeding. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/decongestants/.

Should babies drink water? The answer depends on their age and how they are fed. During hot weather, families may wonder whether their baby needs extra water to prevent dehydration. It is a reasonable concern, but for babies under six months, breast milk or correctly prepared infant formula usually provides all the fluid they need. There is a specific exception for formula-fed babies in particularly hot weather, when a few small sips of cooled, boiled water may be offered alongside their usual milk feeds. Once complementary foods are introduced, from around six months, small sips of water can be offered with meals. Milk remains an important source of fluid and nutrition throughout the first year (NHS, 2021; First Steps Nutrition Trust, 2024, 2026). Milk provides both fluid and nutrition Breast milk contains more than 80% water and provides the fluid a young baby needs, alongside energy and nutrients. Its composition changes during a feed and in response to the baby's needs. Exclusively breastfed babies under six months do not need additional water, even in hot weather. They may want to breastfeed more frequently, often taking shorter feeds to satisfy their thirst. Offering the breast more often provides additional fluid without replacing the nutrition in breast milk (WHO, 2024). Correctly prepared infant formula also provides the fluid and nutrition a baby needs. Formula must always be made using the correct amount of water and powder, following the manufacturer's instructions. Adding extra water to a feed changes its nutritional composition and can be dangerous (NHS, 2023). Water before six months For babies under six months, the usual recommendation is to meet fluid needs through breast milk or correctly prepared infant formula. Giving additional water can fill a baby's small stomach without providing energy or nutrients. If water replaces some of a milk feed, the baby may take in less of the nutrition needed for growth. Giving too much water can also disturb the balance of sodium and other electrolytes in a young baby's body. This can cause water intoxication, also known as hyponatraemia, which can be serious. Young babies are particularly vulnerable because their kidneys are still developing and have a limited ability to regulate excess water (First Steps Nutrition Trust, 2024). Breastfed babies Exclusively breastfed babies under six months do not need additional water, including during hot weather. Offer breastfeeds in response to the baby's cues; feeds may become shorter and more frequent when it is hot. Combination-fed babies For babies receiving both breast milk and formula, continue offering their usual milk feeds. If the baby is also breastfeeding, offering the breast more frequently can provide additional fluid. Additional water is not routinely needed before six months and should not replace either breast milk or formula. Exclusively expressed breast milk Babies receiving expressed breast milk still receive the fluid they need from their milk. If a baby appears thirstier in hot weather, offer additional expressed breast milk. The person expressing may need to express more frequently to provide the additional milk required. Milk production is regulated by milk removal, so reducing expression can affect the amount of milk produced (Kent, Prime and Garbin, 2012). For practical guidance, see How to Express Breastmilk and Antenatal Hand Expression. Formula-fed babies According to the NHS (2021), formula-fed babies under six months may need a few small sips of cooled, boiled water during particularly hot weather, in addition to their usual formula feeds. The guidance does not specify an exact volume. Water should be offered between milk feeds and should not be given in quantities that replace a feed. Tap water must be boiled and allowed to cool before being offered to a baby under six months. Bottled water is not routinely recommended because it can contain higher levels of sodium or sulphate. Formula must always be prepared using the correct amount of water and powder. Never add extra water to a prepared feed or reduce the amount of powder (NHS, 2021, 2023; First Steps Nutrition Trust, 2024, 2026). Introducing water alongside complementary foods Once a baby is around six months and has started eating solid foods, small sips of water can be offered with meals. Water can be given in an open cup or a free-flow cup without a valve, allowing the baby to practise sipping. There is no need to boil tap water for babies over six months. Breast milk or first infant formula should remain the main drink during the first year, continuing to provide important fluid and nutrition as solid food intake increases. There is no single prescribed volume of water that every baby aged six to twelve months needs. Offer small amounts with meals and allow the baby to decide whether they want to drink. Water should complement milk feeds and food, rather than displace them (NHS, 2021; SACN, 2018; First Steps Nutrition Trust, 2024). Water and health concerns Families sometimes consider offering water when a baby is constipated or unwell. The right approach depends on the baby's age, symptoms and level of hydration. Constipation Water is not a routine treatment for constipation in babies under six months. Changes in stool frequency can occur during infancy, particularly in breastfed babies, and infrequent stools do not necessarily mean a baby is constipated. Stool consistency and whether the baby is distressed or struggling to pass it are also relevant. Once complementary foods have been introduced, small sips of water can be offered with meals. Persistent constipation, hard stools, blood in the stool or significant discomfort should be discussed with a healthcare professional rather than managed by simply increasing water (NICE, 2017). For more information, see Infant constipation and dyschezia. Vomiting and diarrhoea Tummy bugs can cause vomiting and diarrhoea, resulting in fluid loss. Babies, particularly those under six months, can become dehydrated more quickly than older children. Continue offering usual milk feeds. Breastfeeding can continue as often as the baby wants. If a baby is struggling to manage their usual bottle feeds, offer smaller, more frequent feeds to allow fluid to be absorbed more gradually and improve tolerance. If vomiting or diarrhoea is frequent, the baby is unable to keep feeds down, has fewer wet nappies or appears unusually sleepy, seek medical advice promptly. Babies who are very young or seem seriously unwell need urgent assessment (NICE, 2009; NHS, 2024). Fever and other illness A baby with a fever may need more frequent milk feeds, particularly if they are feeding less than usual. For babies under six months, continue offering breast milk or correctly prepared formula rather than using plain water to replace milk feeds. For older babies, continue offering milk and their usual small sips of water alongside meals. A baby who is feeding poorly, has fewer wet nappies or seems unusually sleepy may be becoming dehydrated. Seek medical advice if you are concerned, particularly if the baby is very young or has a persistent fever (NHS, 2024). When to seek professional advice Seek advice from a healthcare professional if a baby is feeding less than usual, has fewer wet nappies, is repeatedly vomiting, has ongoing diarrhoea or you are concerned about their hydration. Signs of dehydration can include fewer wet nappies, a dry mouth, fewer tears, sunken eyes or a sunken fontanelle. A baby who is unusually sleepy, difficult to wake, breathing rapidly or appears seriously unwell needs urgent medical assessment (NHS, 2024; NICE, 2009). Different healthcare professionals have different roles in supporting infant feeding and assessing concerns. For more information, see What is an IBCLC? Feeding Support Explained and What does an infant feeding specialist do?. Water guidance by age and feeding method The table below summarises the guidance on offering water during the first year, according to age and feeding method. | Age and feeding method | Water guidance | |---|---| | Under six months – exclusively breastfed | No additional water. Offer extra breastfeeds in hot weather. | | Under six months – combination-fed | Continue usual breast milk and formula feeds. Offer the breast more frequently if needed. No routine additional water. | | Under six months – exclusively expressed breast milk | Offer additional expressed breast milk if needed; express more frequently to provide it. | | Under six months – formula-fed | Continue usual formula feeds. A few small sips of cooled, boiled water may be offered between feeds during particularly hot weather. | | From around six months, once solids have started | Offer small sips of water from an open or free-flow cup with meals. Continue breast milk or first infant formula as the main drink. | Adapted from Lucy Webber, IBCLC (2024), infographic on water intake in infancy. References First Steps Nutrition Trust (2024) FAQ: What are the recommendations for giving water during infancy? June 2024. First Steps Nutrition Trust (2026) ‘Advice on drinks during hot weather, for families with babies and young children’, August 2026. Kent, J.C., Prime, D.K. and Garbin, C.P. (2012) ‘Principles for maintaining or increasing breast milk production’, Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(1), pp. 114–121. doi: 10.1111/j.1552-6909.2011.01313.x. National Institute for Health and Care Excellence (NICE) (2009) Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. Clinical guideline CG84. National Institute for Health and Care Excellence (NICE) (2017) Constipation in children and young people: diagnosis and management. Clinical guideline CG99. NHS (2021) Drinks and cups for babies and young children. NHS (2023) How to make up baby formula. NHS (2024) Dehydration. Scientific Advisory Committee on Nutrition (SACN) (2018) Feeding in the first year of life. London: Public Health England. World Health Organization (WHO) (2024) Breastfeeding: questions and answers. 2 October 2024.

A baby's poo can tell us a lot about their general health. Its colour, consistency and appearance can change as a baby grows, and these changes can be influenced by feeding, digestion and illness. How often a baby passes stool is also useful information, but frequency alone does not determine whether a baby is constipated. Understanding what is normal, recognising the difference between constipation and infant dyschezia, and looking at bowel movements alongside feeding, hydration and growth can help families know when reassurance is appropriate and when to seek support. What normal baby poo looks like A baby's stools change considerably during the first days and weeks of life. These changes are one of several useful indicators of how feeding is progressing. During the first day or two after birth, babies usually pass meconium. This first stool is dark green or black, sticky and thick. As milk intake increases, the stool changes in colour and consistency. By around days four to five, stools usually become lighter and looser. Breastfed babies commonly have yellow or mustard-coloured stools that may look grainy or contain small seed-like flecks. Formula-fed babies generally have stools that are firmer, more paste-like and darker in colour. Both can be normal (NHS, 2021; Derbyshire Family Health Service, n.d.). Green stools Green poo is not automatically a cause for concern. It can be normal, and some infant formulas can make stools appear dark green. However, green stools can also occur alongside changes in digestion, infection or feeding difficulties. Green, frothy stools may sometimes occur when a baby is experiencing a high milk flow, oversupply or difficulties transferring milk effectively. Temporary lactose overload can also occur, including after gastroenteritis. These possibilities need to be considered alongside the baby's feeding behaviour, comfort, weight gain and overall wellbeing. Stool colour alone cannot identify the cause (NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board, 2026). If green stools are persistent or accompanied by diarrhoea, significant discomfort, poor feeding or concerns about growth, seek advice from a health visitor or GP. Pale, bloody or black stools Very pale, chalky or white stools are not typical and can indicate a problem with bile flow or the liver. Seek urgent medical advice if you notice them. Blood in a baby's stool should also be discussed with a healthcare professional, particularly if it is unexplained, recurrent or accompanied by other symptoms. A small streak of bright red blood can sometimes occur when a hard stool causes a small tear around the anus, but this should not be assumed to be the cause without appropriate assessment. Black, tar-like stools are expected in the first days after birth while a baby passes meconium. Black stools later on, when meconium has passed, need medical assessment unless a healthcare professional has explained another cause. Feeding, milk intake and growth Feeding and bowel movements are closely connected. The amount of milk a baby receives, how effectively they transfer it and how well they grow can all help put stool patterns into context. In the first weeks, stool frequency is a useful indicator of milk intake, particularly for breastfed babies. A breastfed baby aged between four days and six weeks who is feeding well should usually pass at least two yellow stools a day. If there has been no stool for 24–48 hours during this period, speak to a midwife or health visitor because it may indicate that the baby is not receiving enough milk (NHS, 2023a). After around six weeks, some breastfed babies begin to poo much less frequently. A baby may go several days without a bowel movement, and occasionally longer, while still being well and growing normally. If the stool is soft when it arrives and the baby is feeding and growing well, this is not necessarily constipation. Formula-fed babies often continue to pass stools more regularly, although patterns vary. If a formula-fed baby is younger than eight weeks and has not passed a stool for two to three days, seek advice from a midwife, health visitor or GP (NHS, 2023b). Preparing formula safely Always prepare formula using the exact amount of water and powder specified by the manufacturer. Adding extra powder can make feeds too concentrated, potentially contributing to constipation and dehydration. Adding extra water can make a feed too dilute and may be dangerous. The volume suggested on formula packaging is a guide, not a target every baby must finish. Babies vary in their needs, and feeding should respond to their cues rather than pressure to finish a bottle. For an independent guide to infant milk, including how to interpret formula information, see First Steps Nutrition Trust's *Infant milks: a simple guide to infant formula, follow-on formula and other infant milks*, particularly page 18 (First Steps Nutrition Trust, 2024). Responsive bottle feeding and recognising feeding cues can also help families understand whether a baby is taking enough milk without being encouraged to overfeed. For further information, see What is an IBCLC? Feeding support explained and What does an infant feeding specialist do?. A holistic approach Bowel movements should be considered alongside the whole feeding picture, rather than in isolation. Useful information includes: How often the baby feeds and how feeds are going. Whether the baby appears comfortable during feeding and afterwards. Whether milk transfer seems effective and the baby is satisfied after feeds. The number of wet nappies and any signs of dehydration. Weight gain and the baby's general health. Stool colour, consistency, frequency and any changes from the baby's usual pattern. For breastfed babies, persistent green, frothy stools may be one part of a wider picture involving milk flow, oversupply or milk transfer. It is not possible to diagnose ineffective milk transfer, lactose overload or an allergy from stool appearance alone. A feeding assessment can help identify whether there are difficulties with positioning, attachment, oral function, milk flow or feeding coordination that need support. Cow's milk protein allergy can sometimes be associated with constipation, but constipation on its own is not enough to establish an allergy. Other symptoms and the baby's clinical history need to be considered before making changes to feeding (NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board, 2026). Stooling frequency There is no single bowel movement pattern that is normal for every baby. Frequency changes with age, feeding and the introduction of complementary foods. In the early weeks, frequent stools are common. After around six weeks, some breastfed babies pass stools much less often. Formula-fed babies may continue to poo daily, but there is individual variation. The important distinction is between a baby who passes soft stools infrequently and a baby who passes hard, dry or painful stools. The former may be entirely normal; the latter is more suggestive of constipation. When considering stool frequency, also look at whether the baby is feeding well, producing wet nappies, growing as expected and behaving as usual. A sudden change in pattern or a reduction in stool output alongside other symptoms deserves closer attention. Keeping a short record of bowel movements, feeding, wet nappies and any associated symptoms can help when discussing concerns with a health visitor or GP. Recognising constipation Constipation is more than simply not pooing every day. It usually involves stools that are hard, dry, lumpy or pellet-like, or bowel movements that are painful or difficult to pass. Other possible signs include: Larger or firmer stools than usual. Crying or distress when passing a stool. A small amount of bright red blood associated with a hard stool. A firm or swollen tummy. Reduced appetite or being less settled than usual. A baby may strain, grunt, turn red or cry while passing a soft stool. These behaviours do not necessarily mean they are constipated. Constipation can occur following a change in feeding, when formula is introduced, when complementary foods begin or when a baby is not receiving enough fluid. Incorrectly prepared formula can also contribute. Sometimes no clear cause is identified (NICE, 2010, updated 2017). Cow's milk protein allergy is a possible consideration in some babies with constipation, but it is uncommon for constipation to be the only symptom. Do not remove foods from a breastfeeding parent's diet or switch to specialist formula without appropriate advice. Infant dyschezia: straining without constipation Infant dyschezia is a term used to describe a young baby who strains and cries for a prolonged period before passing a soft stool, or who strains and cries but does not successfully pass one. The baby may turn red or appear to be pushing very hard. This can be upsetting to watch, but it does not necessarily mean the baby is constipated. Young babies are still learning to coordinate the muscles needed to increase pressure in the abdomen while relaxing the pelvic floor to allow a bowel movement. Until this coordination develops, they may appear to struggle even when their stool is soft. Infant dyschezia is recognised in otherwise healthy infants younger than nine months. The diagnostic criteria describe at least ten minutes of straining and crying before a successful or unsuccessful attempt to pass a soft stool. It usually resolves as coordination develops, without medication or other treatment (Rome Foundation, 2016; Benninga et al., 2016). Comforting the baby, cuddling and gentle movements may help them settle. Avoid trying to make the baby poo by stimulating the rectum. This is not necessary for dyschezia and can cause distress or injury. If stools are hard, the baby is unwell, feeding is poor or there are other concerning symptoms, do not assume the problem is dyschezia; seek medical advice. Supporting your baby at home If your baby is otherwise well, feeding normally, producing wet nappies and passing soft stools, there may be no need to intervene simply because they have not pooed as frequently as expected. Some gentle measures may help a baby feel more comfortable: Gently move their legs in a cycling motion while they are lying on their back. Try a gentle tummy massage if your baby is comfortable with it. Offer cuddles and comfort when they are unsettled. Continue to monitor feeding, wet nappies, stool consistency and growth. If your baby has started complementary foods, offer suitable fibre-containing foods such as fruit and vegetables as part of a balanced diet. These measures may help with comfort, but they do not replace assessment if a baby is genuinely constipated or has symptoms that suggest an underlying problem. If you are concerned about feeding effectiveness or milk intake, seek feeding support rather than relying on stool frequency alone. The right support depends on the cause of the difficulty. Water and other home remedies Babies under six months generally receive the fluid they need from breast milk or correctly prepared infant formula. Do not give extra water, sugar water, fruit juice or herbal remedies to a young baby to try to treat constipation unless a healthcare professional has specifically advised you to do so. Never add extra water to formula or change the powder-to-water ratio. This can affect the balance of nutrients and salts a baby receives. For babies who have started complementary feeding, suitable foods and fluids should be offered in line with their age and usual feeding guidance. If constipation persists, seek advice rather than trying repeated home remedies. Approaches to avoid Do not insert anything into a baby's rectum to stimulate a bowel movement. This can injure the rectum or bowel, with a risk of serious injury, including perforation. Rectal stimulation is not a treatment for infant dyschezia. Do not give laxatives, suppositories or enemas unless advised by an appropriate healthcare professional. Some babies with constipation need medication, but the choice and dose depend on their age, symptoms and clinical assessment. Laxatives work in different ways. Stool softeners help make poo softer and easier to pass, while stimulant laxatives help the bowel contract to move stool along. A healthcare professional can advise whether either type is appropriate and whether further assessment is needed. Dietary changes alone may not be enough to treat established constipation (NICE, 2010, updated 2017; NHS England, 2023). When to seek medical advice Speak to your midwife, health visitor or GP if you are worried about your baby's bowel movements, feeding, hydration or growth. Seek advice if stools become hard or painful, there is blood in the stool, your baby is feeding less than usual, or a change in bowel pattern persists. For a breastfed baby aged four days to six weeks, fewer than two yellow stools a day or no stool for 24–48 hours should prompt a discussion with a midwife or health visitor. If a formula-fed baby is under eight weeks and has not passed a stool for two to three days, seek advice from a healthcare professional (NHS, 2023a; NHS, 2023b). Other conditions to consider Constipation that begins at birth or in the first few weeks of life, delayed passage of the first stool, poor growth or a markedly swollen abdomen should not automatically be attributed to ordinary infant constipation. These signs can sometimes indicate an underlying medical condition and require prompt assessment (NICE, 2010, updated 2017; NHS England, 2023). One such condition is Hirschsprung's disease, in which nerve cells that help move stool through part of the bowel are missing. This can make it difficult for stool to pass. Delayed passage of meconium, abdominal swelling, vomiting and ongoing constipation can be warning signs (NHS, 2017). Pyloric stenosis is another condition to be aware of in young infants. It is a narrowing at the outlet of the stomach, which prevents milk from passing normally into the small intestine. Repeated, forceful or projectile vomiting is a key symptom; because less milk reaches the bowel, stool output may also reduce. Projectile vomiting in a young baby needs urgent medical assessment (NICE, 2015, updated 2019; Great Ormond Street Hospital for Children NHS Foundation Trust, n.d.). Seek urgent medical help if your baby has green vomit, repeated projectile vomiting, a very swollen abdomen, marked lethargy, signs of dehydration or is difficult to wake. Contact a healthcare professional promptly if your baby's poo is very pale, there is unexplained blood in the stool, your baby is not feeding normally or you are concerned about their weight gain. If your baby appears seriously unwell, seek emergency help. Understanding bowel movements means looking beyond how often a baby poos. Stool appearance, feeding effectiveness, hydration, growth and the baby's overall wellbeing all provide important information. If you are unsure, seeking support can help establish whether the pattern is normal, whether constipation needs treatment or whether further assessment is needed. Anatomy provides information; function provides context. References Benninga, M.A. et al. (2016) ‘Childhood functional gastrointestinal disorders: neonate/toddler’, Gastroenterology, 150(6), pp. 1443–1455.e2. Available at: https://doi.org/10.1053/j.gastro.2016.02.016 Derbyshire Family Health Service (n.d.) A guide to your baby’s poo and wee. Available at: https://derbyshirefamilyhealthservice.nhs.uk/our-services/0-5-years/babies-health-and-wellbeing/baby-poo-wee First Steps Nutrition Trust (2024) Infant milks: a simple guide to infant formula, follow-on formula and other infant milks. Available at: https://www.firststepsnutrition.org/s/Infant-milks-a-simple-guideJuly24_final.pdf Great Ormond Street Hospital for Children NHS Foundation Trust (n.d.) Pyloric stenosis. Available at: https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/pyloric-stenosis/ National Institute for Health and Care Excellence (NICE) (2010, updated 2017) Constipation in children and young people: diagnosis and management (CG99). Available at: https://www.nice.org.uk/guidance/cg99 National Institute for Health and Care Excellence (NICE) (2015, updated 2019) Gastro-oesophageal reflux disease in children and young people: diagnosis and management (NG1). Available at: https://www.nice.org.uk/guidance/ng1 NHS (2017) Hirschsprung’s disease. Available at: https://www.nhs.uk/conditions/hirschsprungs-disease/ NHS (2021) How to change your baby’s nappy. Available at: https://www.nhs.uk/baby/caring-for-a-newborn/how-to-change-your-babys-nappy/ NHS (2023a) Constipation and breastfeeding. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/breastfeeding-challenges/constipation/ NHS (2023b) Constipation and bottle feeding. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-challenges/constipation-and-bottle-feeding/ NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (2026) Cow’s milk protein allergy guidelines. Available at: https://bswtogether.org.uk/medicines/wp-content/uploads/sites/3/2026/04/CMPA-BSW-CMPA-Guidelines-Update-Feb-2026.pdf NHS England (2023) National clinical constipation pathway for primary care for children. Available at: https://www.england.nhs.uk/long-read/national-clinical-constipation-pathway-for-children/ Rome Foundation (2016) Rome IV criteria: childhood functional gastrointestinal disorders. Available at: https://theromefoundation.org/rome-iv/rome-iv-criteria/

Scissor frenulotomy is a brief procedure used to divide a restrictive lingual frenulum beneath an infant’s tongue. It has been performed for many years, and serious complications appear uncommon. However, no procedure is entirely without risk, and families need balanced information before deciding whether it is appropriate for their baby. This article focuses on simple scissor frenulotomy in infants under 12 months of age, or before the upper teeth erupt if that happens sooner. It does not cover laser procedures, more extensive oral surgery or procedures undertaken in older children. The decision to divide a tongue-tie should follow an assessment of feeding function, not appearance alone. A visible frenulum does not automatically mean that it is restricting tongue movement or causing feeding difficulties. As the saying goes, anatomy provides information; function provides context. Families may find it helpful to read Surgical release or conservative management for my baby's tongue-tie alongside this article. What the evidence tells us The National Institute for Health and Care Excellence (NICE, 2005) concluded that the evidence available at the time was adequate to support the use of division of tongue-tie in infants with breastfeeding difficulties, provided normal arrangements were in place for consent, audit and clinical governance. NICE also recognised that complications were possible. A Cochrane review by O’Shea et al. (2017) examined five randomised controlled trials involving 302 infants. The trials did not report excessive bleeding, infection requiring treatment or damage to the tongue or submandibular ducts. The absence of a reported event in these studies does not prove that the risk is zero. A different source of information is the Association of Tongue-tie Practitioners (ATP) audit published in 2025. It received 46 responses covering 8,061 procedures. Respondents reported five ambulance calls, approximately 0.06% of the procedures represented in the audit, four cases of bleeding requiring medical intervention and one hospital transfer. No confirmed infections were reported by respondents. These figures are useful for understanding the experiences reported by participating practitioners, but they should not be interpreted as a complete national complication rate. The audit was voluntary, relied on practitioner responses and cannot capture every procedure or every complication. Submission of data by all practitioners and NHS services is not mandatory, so complete national figures are not available. Bleeding Bleeding is an expected potential risk when tissue is divided. The amount varies between infants, and most bleeding following a simple scissor frenulotomy is limited. In a case series of 215 infants, Griffiths (2004) reported no bleeding in 84 infants (39%), a few drops in 113 (53%) and a small amount in 18 (8%). None of the infants needed pressure applied for as long as one minute to control the bleeding, and no delayed primary or secondary haemorrhage was reported. These findings are reassuring, although they cannot guarantee that every infant will have the same experience. A simple frenulotomy divides the lingual frenulum in the midline. It is not intended to divide the lingual arteries. Nevertheless, the floor of the mouth contains blood vessels, and significant bleeding, although uncommon, can occur. Vitamin K and blood clotting disorders Vitamin K is essential for normal blood clotting. Newborn babies have naturally low vitamin K stores, which is why vitamin K is routinely offered after birth to prevent vitamin K deficiency bleeding (VKDB). Babies who have not received vitamin K, or whose course is incomplete, may be at increased risk of serious bleeding after a procedure. Inherited or acquired blood clotting disorders can also increase the risk of bleeding. These include conditions affecting clotting factors, such as haemophilia, and disorders affecting platelets or their function. Some conditions may not have been diagnosed in an infant before their first procedure. A family history of unusual or prolonged bleeding, excessive bleeding after surgery or dental procedures, or a known bleeding disorder should therefore be explored during the pre-procedure assessment. A baby can appear healthy and still have an underlying clotting disorder. Where there is a known or suspected bleeding disorder, or uncertainty about vitamin K prophylaxis, the practitioner must assess whether it is safe to proceed and seek appropriate medical advice where necessary. The procedure should not go ahead until any relevant risk has been adequately addressed. Read more in Vitamin K and Tongue-tie Division and Blood clotting disorders and Tongue-tie division. Delayed or persistent bleeding Bleeding can occasionally begin or recur after the infant has left the clinic. Disturbance of the wound may contribute, but persistent bleeding should not automatically be attributed to normal healing or to the infant crying. Families should receive clear, written instructions about what to do if bleeding occurs, including how to contact the practitioner and when to seek emergency help. The ATP has published bleeding management guidance, including guidance on prolonged bleeding. If bleeding continues or cannot be controlled after the advised measures have been followed, urgent medical assessment is needed. If bleeding is persistent or uncontrolled, families should call 999. The purpose of this advice is not to suggest that a small initial amount of blood is an emergency, but to ensure that a rare serious complication is not overlooked. Pain Pain during and after infant frenulotomy is difficult to measure because babies cannot describe their experience. Crying is one possible response, but it does not provide a precise measure of pain intensity. In Griffiths’ (2004) study, 39 of 215 infants (18%) slept throughout the procedure. Sixty per cent cried more during or after division, with the average period of increased crying reported as 0–15 seconds. Eighty-five per cent cried for 20 seconds or less, while two infants cried for more than one minute. The study did not use an anaesthetic or analgesic. These findings describe the responses seen in that particular group; they do not establish that every infant experiences the procedure in the same way. Anatomical research by Mills et al. (2019), identified branches of the lingual nerve close to the surface of the underside of the tongue, with small branches extending towards the frenulum. This demonstrates that sensory nerve structures are present in the region. It does not tell us precisely how much pain an individual baby experiences during a brief division, nor does it establish that the frenulum lacks pain sensation. Some infants settle quickly and appear comfortable after the procedure. In others, swallowed air (aerophagia) may accumulate throughout the day, contributing to discomfort that becomes more noticeable during the evening ‘witching hour’. This may be mistaken for pain from the healing wound, when trapped gas could instead be contributing to the infant’s unsettled behaviour. Pain relief should be discussed with the practitioner, taking the infant’s age, weight and individual circumstances into account. Paracetamol may be appropriate for some infants when they are old enough and it is given in accordance with the relevant product instructions and professional advice. Ibuprofen is not suitable for all infants, particularly very young or low-weight babies, and should only be considered when age and other eligibility criteria are met. The ATP’s position statements provide further guidance on frenulotomy in different age groups. The practitioner should explain the approach to comfort and pain relief before consent is given. Injury to surrounding structures The floor of the mouth contains delicate tissues, blood vessels, nerves and salivary ducts. Accidental injury to the tongue or surrounding structures is a recognised but apparently rare complication of infant frenulotomy. However, available studies are too limited to establish a reliable risk percentage specifically for simple scissor division. In a Cochrane review, no damage to the tongue or submandibular ducts was reported among 152 infants who underwent frenotomy in the relevant trials, but these numbers are too small to exclude rare injuries. NICE identifies damage to the tongue and the submandibular ducts as possible complications. The submandibular ducts carry saliva into the mouth. Damage to surrounding structures is not a common finding in the small randomised trials reviewed by Cochrane, but those trials were also not large enough to exclude rare injuries. The practitioner's training, experience, knowledge of anatomy and ability to recognise when a procedure is inappropriate are important safeguards. Families should be able to ask about the practitioner's qualifications, experience, clinical governance and arrangements for managing complications. Infection Any procedure that breaks the skin or mucosal surface carries a potential risk of infection. The mouth contains many microorganisms, but this does not mean that infection will necessarily follow a frenulotomy. The ATP's 2025 audit covered 8,061 procedures, with no confirmed infections reported. However, participation was voluntary, and the audit relied on information submitted by respondents. This finding should therefore not be interpreted as proof that infections never occur or as a definitive national infection rate. Wound healing and reformation After a simple scissor frenulotomy, the wound is generally left open to heal naturally. Stitches are not routinely used. A pale cream or yellow-white appearance can develop over the wound as part of normal healing. It may look like an ulcer or a layer of material over the tissue, but its appearance alone does not establish that infection is present. The healing process and the appearance of the wound are explained in more detail in Wound healing in infants after a tongue-tie release. It is important to distinguish between different outcomes during and after healing: Normal healing: the wound changes in appearance as the surface heals. A pale cream or yellow-white coating forms and does not, by itself, indicate infection. Reformation or readherence: as the wound heals, tissue may reconnect across the divided area, potentially restricting tongue movement again. Residual restriction: some restriction may remain following division. The significance of this depends on the infant's tongue function and feeding, rather than the appearance of the wound alone. Thickened or hypertrophic scar tissue: scar tissue may become raised or thickened during healing. Its presence does not automatically mean that tongue function is impaired, but where movement or feeding is affected, further assessment may be appropriate. These outcomes are not interchangeable. The appearance of the healing wound alone cannot establish whether restriction has returned, whether scar tissue is affecting movement, or whether the infant's functional difficulties have another explanation. These are not interchangeable explanations, and a wound's appearance cannot by itself determine which has occurred. The ATP has discussed reformation and aftercare in its position statements. Its published estimates have placed reformation at around 2–4%. This is an estimate, not a guaranteed rate for an individual practitioner or baby. Rates from international studies may not be directly comparable because populations, definitions, aftercare practices and techniques differ, including the use of laser and other instruments. Wound management and tongue function Wound stretching or deliberately disrupting a healing wound is different from supporting normal tongue movement and function. The ATP has a position statement on disruptive wound management. Families should receive clear advice from their practitioner about what is recommended and what should be avoided. Feeding itself involves tongue movement. Some infants may also benefit from appropriate tongue-function activities, where these are indicated and taught by a suitably qualified practitioner. Such activities should not be confused with forcibly reopening a wound. Further reading includes Beyond the tongue-tie release: why aftercare matters. Any exercises should be appropriate to the individual infant and should not be painful or coercive. Repeat procedures Some infants undergo a second procedure because a restriction remains, function has not improved sufficiently, or tissue has reconnected. A repeat procedure should not be an automatic response to ongoing feeding difficulties. Before considering further division, the practitioner should reassess tongue function, feeding, healing and the original indication for treatment. Other factors may be contributing, including feeding mechanics, oral-motor difficulties, tone, positioning, milk flow or the need for further feeding support. Repeatedly cutting tissue, particularly where scar tissue has developed, may not resolve the underlying problem and can potentially make matters more complicated. The decision should be based on a fresh assessment of the likely benefit and risk, rather than the assumption that more division will produce a better result. When feeding does not improve A frenulotomy does not guarantee that feeding difficulties will resolve. Some families notice a change quickly, while other infants need time, feeding support and opportunities to develop more effective movement and coordination. Muscles and feeding skills do not necessarily change immediately after a restriction is released. If there is little or no improvement, the practitioner should be informed so that progress can be reviewed. It is important to revisit the original concerns and consider whether the frenulum was the main cause, whether the division has achieved its intended functional outcome, or whether another factor needs attention. Manual bodywork or other supportive approaches may be considered where appropriate, but they should not replace a proper reassessment of feeding and oral function. Families should not be left to assume that persistent difficulties mean they need another procedure. Further reading includes Bottle-feeding with a restriction, Beyond the tongue-tie release: why aftercare matters and Tongue-tie research: the evidence 2026. Making an informed decision Simple scissor frenulotomy is usually brief, and the available evidence suggests that serious complications are uncommon. However, small trials and voluntary audits cannot provide a precise estimate of every possible risk, all of which need to be discussed honestly. Families who would like to understand more about the instruments and techniques used can read How is a tongue-tie release performed in infants?. The decision should balance the infant’s current functional difficulties, the likely benefit of division, the alternatives and the risks of proceeding. It should also take account of the practitioner's assessment, the family's priorities and the support available afterwards. Understanding the differences between procedural approaches may help families make an informed decision; further information is available in Surgical release or conservative management for my baby's tongue-tie. Consent is meaningful when families have time to ask questions, understand the uncertainties and make a decision without pressure. Choosing not to proceed immediately, or deciding to continue with conservative feeding support, can be reasonable when the expected benefits are uncertain or the assessment is incomplete. The aim is not simply to divide a visible piece of tissue. It is to help an infant feed and function more comfortably, while avoiding unnecessary intervention and ensuring that any procedure is undertaken with appropriate skill, consent and follow-up. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’. Breastfeeding Medicine, 16(4), pp. 278–281. https://doi.org/10.1089/bfm.2021.29179.ylf Association of Tongue-tie Practitioners (ATP) (2022) Position statement on disruptive wound management. Available at: https://www.tongue-tie.org.uk/position-statements Association of Tongue-tie Practitioners (ATP) (2024) Position statement on frenulotomy (surgical release of tongue-tie) in different age groups. Available at: https://www.tongue-tie.org.uk/position-statements Association of Tongue-tie Practitioners (ATP) (2025) Audit of tongue-tie divisions. Audit findings reported by participating practitioners. Association of Tongue-tie Practitioners (ATP) (2026) Bleeding guidelines. Available at: https://www.tongue-tie.org.uk/bleeding-guidelines Griffiths, D.M. (2004) ‘Do tongue ties affect breastfeeding?’, Journal of Human Lactation, 20(4), pp. 409–414. https://doi.org/10.1177/0890334404266976 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(6), pp. 824–835. https://doi.org/10.1002/ca.23410 National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance IPG149. Available at: https://www.nice.org.uk/guidance/ipg149 O’Connor, M.E., Gilliland, A.M. and LeFort, Y. (2022) ‘Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey’, International Breastfeeding Journal, 17, article 39. https://doi.org/10.1186/s13006-022-00481-w 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. https://doi.org/10.1002/14651858.CD011065.pub2 Wilson, [bibliographic details to be confirmed] (2016). Study cited in the literature on pain following infant frenotomy. Full reference requires verification before publication.

Breast milk production is a dynamic physiological process, influenced by hormonal changes, milk removal and the mammary gland's response to how much milk remains within the breast. Following birth, milk production develops rapidly before becoming increasingly regulated by the frequency and effectiveness of milk removal. This relationship is central to understanding why an infant's feeding difficulties can affect ongoing milk production (Neville and Morton, 2001; Pang and Hartmann, 2007). When an infant cannot transfer milk effectively, the immediate concern is whether they are receiving enough milk to meet their nutritional needs. Alongside this, it is important to consider how milk production will be maintained while feeding difficulties are assessed and addressed. An infant may struggle to obtain milk despite an adequate capacity for production, but persistent ineffective milk removal can subsequently contribute to a reduction in supply (Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3, 2023). Protecting milk production therefore involves understanding the physiology of lactation, recognising when milk removal may be insufficient and supporting continued production while the reasons for ineffective feeding are explored. This is distinct from the techniques used to express milk, provide supplementary feeds or support bottle feeding, although these may form part of an individual feeding plan. How breast milk production develops Lactation begins before birth. During pregnancy, hormonal changes stimulate the development of the mammary glands and prepare them for milk production. This early phase, known as lactogenesis I, involves the differentiation of milk-producing cells and the production of colostrum. Following the birth of the placenta, progesterone levels fall substantially. In the presence of prolactin and other necessary hormonal signals, this change triggers secretory activation, commonly called lactogenesis II. Milk volume generally increases noticeably over the first few days after birth, although the timing varies between individuals (Neville and Morton, 2001). The onset of copious milk production is not entirely dependent on how effectively an infant feeds. Hormonal changes initiate this transition, which can occur even when an infant is unable to feed directly at the breast. However, early milk removal is important to the subsequent development and maintenance of production. Delayed secretory activation and ineffective early milk removal may occur together, making it important to consider both the lactating person's physiology and the infant's feeding ability. As lactation becomes established, regulation increasingly depends on local processes within the mammary gland and the amount of milk removed. This later phase is often described as lactogenesis III or established lactation. Hormones remain important, but circulating hormone levels alone do not determine how much milk is produced (Pang and Hartmann, 2007). Prolactin, oxytocin and milk removal Prolactin and oxytocin have different but complementary roles in lactation. Prolactin supports milk synthesis within the mammary alveoli, the small structures where milk is produced. Suckling and other forms of effective breast stimulation can trigger prolactin release. However, the relationship between circulating prolactin concentrations and milk volume is not straightforward. A higher prolactin concentration does not automatically mean that more milk will be produced, particularly once lactation is established. Oxytocin supports milk ejection. When released into the bloodstream, it causes the myoepithelial cells surrounding the alveoli to contract, moving milk towards the ducts and making it available for removal. This is commonly called the milk ejection or let-down reflex. Milk synthesis and milk ejection are therefore distinct processes. A person may be producing milk but experience difficulty with its ejection, while another may have an effective milk ejection reflex but produce less milk than their infant needs. Neither process should be assessed in isolation from milk transfer and the wider feeding picture (Pang and Hartmann, 2007). Oxytocin release can be influenced by sensory cues associated with the infant and feeding, as well as the individual's circumstances and experience. Pain, anxiety and an unfamiliar environment may affect the feeding experience and milk ejection for some people. This does not mean that a person can think themselves into producing more milk, or that emotional difficulty is the explanation for every problem with milk transfer. Why milk removal influences ongoing production Once lactation is established, the amount of milk removed becomes an important regulator of the amount produced. When milk is removed regularly and effectively, the mammary gland receives signals that support continued synthesis. When milk accumulates and remains in the breast, local regulatory processes can slow further production (Pang and Hartmann, 2007). This helps explain why a reduction in milk removal can affect supply even when milk production was initially adequate. If an infant repeatedly removes less milk than the breast is capable of providing, the breast may respond by producing less over time. The relationship is not a simple on-off switch, and one missed feed does not inevitably cause a lasting reduction in production. The effect depends on the stage of lactation, the amount of milk normally removed, the duration and extent of the change, and individual physiology. It is also important to distinguish between milk being available in the breast and milk being successfully transferred to the infant. The amount an infant receives during a feed depends on milk availability, milk ejection and the infant's ability to remove and swallow milk. A person can have milk available without their infant being able to obtain it efficiently. Research examining the relationship between infant factors and human milk secretion identifies milk removal as an important influence on ongoing production. It also highlights how infant characteristics can affect the effectiveness of this process (Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3, 2023). How infants remove milk from the breast Effective milk transfer requires coordinated oral movements and the ability to generate and maintain the pressures needed to remove milk. It is not simply a matter of an infant being attached to the nipple or appearing to suck. Ultrasound research has helped clarify the mechanics of breastfeeding. Infant tongue movement, jaw movement and intra-oral vacuum work together during milk removal. Negative pressure, or suction, has a particularly important role in drawing milk from the breast. Tongue and jaw movements contribute to the changing shape of the oral cavity and the coordination of milk removal and swallowing (Geddes et al., 2008). The infant must also coordinate sucking, swallowing and breathing. Milk needs to be transferred into the mouth and swallowed while breathing is appropriately coordinated. An infant who is premature, unwell, fatigued or still developing feeding skills may find this more difficult. Oral motor function, attachment, positioning and other anatomical or physiological factors may also affect milk transfer (Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3, 2023). A feed can therefore look active without being effective. An infant may remain at the breast for a long time, repeatedly attach and detach, or continue sucking with limited swallowing. These behaviours are not diagnostic on their own, but they can provide reasons to assess feeding effectiveness in context. My articles on recognising infant swallowing during feeds and breastfeeding latch and positioning explore these aspects of feeding in more detail. Milk transfer, milk production and infant intake Milk transfer, milk production and infant intake are closely connected, but they are not interchangeable. Milk production describes the volume of milk the lactating person's body synthesises. Milk transfer describes how effectively milk moves from the breast to the infant. Infant intake is the amount of milk the infant actually receives. These distinctions matter because a feeding difficulty does not automatically establish low milk production. An infant may transfer milk inefficiently despite an adequate milk supply. Conversely, an infant may feed effectively but receive less milk than needed because production is insufficient. Sometimes both difficulties occur together. If an infant transfers milk poorly over time, reduced removal may contribute to a decline in production. The original difficulty can then become more complicated: the infant may continue to struggle with milk transfer while the amount of milk available also decreases. The relationship can be represented as a cycle: 1. Ineffective milk transfer means less milk is removed than intended. 2. Reduced milk removal can signal the breast to decrease production. 3. Lower production may reduce the milk available at subsequent feeds. 4. The infant may then receive less milk overall, increasing the importance of assessment and support. This cycle is a possible consequence of persistent ineffective milk removal, not an inevitable outcome of every difficult feed. It is also not the only explanation for low milk production. Maternal health, breast development, previous breast surgery, hormonal conditions, medication and the circumstances surrounding birth may all be relevant (Neville and Morton, 2001; Pang and Hartmann, 2007). Protecting an established milk supply when transfer is ineffective When an infant cannot remove milk effectively from the breast, protecting the existing milk supply becomes an important consideration. The aim is to maintain the milk production that is already established while the infant's feeding difficulties are assessed and addressed. This is different from increasing milk production. If a lactating person is producing enough milk but their infant cannot transfer it effectively, the immediate aim may be to replace ineffective or missed milk removals. If production is already insufficient, additional support may be needed to increase it. These goals can overlap, but they are not interchangeable, and a plan should reflect the individual circumstances (Slater and Spatz, 2025; Spatz et al., 2025). Milk accumulation within the breast can slow further synthesis through local regulatory mechanisms. If milk is repeatedly left unremoved, production may decrease over time. This is an adaptive physiological response, rather than evidence that the body has permanently lost the ability to produce milk. The extent to which production changes depends on the amount and frequency of milk removal, the stage of lactation and individual factors (Pang and Hartmann, 2007; Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3, 2023). Protecting supply can therefore help prevent a second problem developing alongside the original feeding difficulty. An infant who struggles to transfer milk may initially be feeding from a breast capable of producing an adequate volume. If ineffective transfer continues without sufficient alternative milk removal, production may subsequently fall, making it harder to meet the infant's needs. Practical ways to protect milk production The appropriate approach depends on the infant's age, feeding effectiveness, the established milk supply and the family's circumstances. The following are options to discuss with an appropriately qualified infant-feeding professional. Continue offering the breast responsively where appropriate. Frequent opportunities to feed support breast stimulation, but time spent attached to the breast does not necessarily mean that milk is being removed effectively. If transfer is limited, direct feeding may need to be supported by another method of milk removal (NICE, 2021; Spatz et al., 2025). Express when the infant cannot remove milk effectively. Hand expression or a breast pump can provide milk removal when direct feeding is ineffective or not possible. This helps maintain stimulation and may provide expressed milk for the infant. The method should be comfortable and practical for the individual (Becker, Smith and Cooney, 2022). Consider the frequency and effectiveness of milk removal across 24 hours. The aim is to avoid a sustained reduction in milk removal compared with what is needed to maintain the person's established production. The appropriate frequency varies with the infant's age, the stage of lactation and the clinical situation. A plan for a newborn whose feeding is ineffective may differ considerably from one for an older infant (Spatz et al., 2025). Consider overnight milk removal where necessary. Prolactin follows a daily rhythm, and milk removal overnight may be particularly relevant when establishing production or protecting a vulnerable supply. However, the plan should balance physiological needs with the lactating person's recovery, sleep and wellbeing rather than impose an unsustainable schedule (Spatz et al., 2025). Review pump comfort and effectiveness. Poor flange fit, excessive suction or painful pumping can make expression difficult to sustain. The aim is comfortable, effective milk removal, not the highest possible suction setting. See Breast Pump Flange Fitting: Size, Shape, Comfort and Milk Removal. Consider how supplementation affects breast stimulation. If supplementary milk replaces a breastfeed, milk may need to be removed by expression if maintaining supply is a goal. Supplementation should not be delayed or withheld when the infant needs additional nutrition; the feeding and milk-removal plans should be considered together (Kellams et al., 2017). Make the plan sustainable. Pain, exhaustion, separation, limited access to equipment and the demands of caring for an infant can all affect how feasible a plan is. Practical help and regular review can make a difference. A plan that cannot realistically be maintained needs to be reconsidered, not treated as a personal failure. These measures support milk removal, but they do not necessarily resolve the reason an infant is struggling to feed. They should sit alongside assessment and support for the underlying difficulty. When milk production needs to increase If milk production is already below the volume needed or desired, maintaining the current pattern of milk removal may not be enough. Increasing production may require more frequent or more effective milk removal, alongside assessment of factors affecting lactation. The response varies between individuals, and increasing production cannot be guaranteed. Relactation, which involves re-establishing milk production after breastfeeding or lactation has stopped or substantially reduced, is also an option for some families. It may be possible to restore some or all milk production with appropriate support, although the outcome and timescale vary. Relactation is not the main focus of this article, but it illustrates the capacity of lactation to respond to renewed stimulation and milk removal (World Health Organization, 1998). Whether the aim is to maintain an established supply, increase production or re-establish lactation, the infant's nutritional needs must remain protected. Supplementation should continue as clinically needed while milk production and transfer are assessed. Supplementation and the physiology of supply Supplementation may be necessary when an infant is not receiving enough milk. It can be part of a temporary plan while feeding is assessed, or part of a longer-term feeding arrangement that suits the family. The effect of supplementation on milk production depends partly on whether milk removal from the breast continues. If a supplement replaces a breastfeed and no milk is removed at that time, the breast receives less stimulation and milk removal than it otherwise might. Repeated over time, this may contribute to a reduction in production. This is why supplementation and supply protection are best considered together when maintaining lactation is a goal. Supplementation itself does not inevitably reduce supply, and necessary supplements should not be withheld to protect breastfeeding. The priority is adequate infant nutrition, with an appropriate plan for milk removal where the lactating person wishes to maintain or increase production (Kellams et al., 2017). The method used to offer supplementary milk is a separate consideration. Responsive bottle feeding and paced feeding can support the infant's ability to communicate feeding cues and take pauses, but these methods do not replace breast stimulation when milk transfer at the breast is insufficient. See your existing article on paced bottle feeding for practical guidance on responsive bottle feeding. Galactagogues and milk production Galactagogues are medicines, herbs or other substances used with the intention of increasing milk production. Some may have a role in specific circumstances, but they do not replace the need to assess milk removal and the reasons for reduced production. The physiological distinction between milk synthesis and milk transfer is important here. A substance intended to increase production cannot, on its own, correct an infant's difficulty generating effective suction, coordinating feeding or transferring milk. Where milk removal is limited, addressing that limitation is a central part of the plan. The Academy of Breastfeeding Medicine recommends identifying and addressing potentially modifiable factors before considering galactagogues. Evidence varies between agents, and an increase in a hormone such as prolactin does not guarantee a meaningful increase in milk volume (Brodribb, 2018). For a fuller discussion of the evidence, benefits and limitations of these interventions, see your existing article on galactagogues. When to seek feeding support and investigate the underlying cause Families should seek skilled feeding support promptly when there are concerns about ineffective milk transfer, persistent pain, damaged nipples, repeated difficulty attaching, very prolonged feeds with little apparent swallowing, or concerns about the infant's intake or growth. A change in feeding, reduced wet nappies, increasing jaundice, unusual sleepiness or difficulty waking for feeds warrants timely assessment. An infant who is difficult to rouse, appears seriously unwell or shows signs of significant dehydration needs urgent medical assessment. These signs do not identify a single cause. They indicate the need to assess the infant's intake and feeding effectiveness rather than relying on reassurance or a single observation. NHS guidance advises families concerned about milk supply or whether their baby is receiving enough milk to seek help from their midwife, health visitor or breastfeeding specialist (NHS, n.d.). A professional supporting the feeding dyad should work with the family on two connected priorities: maintaining or restoring milk production where this is a goal, and investigating why effective milk transfer is not occurring naturally. Protecting supply is an important part of care, but it should not become a substitute for understanding the feeding difficulty. Assessment may include observing a feed, considering positioning and attachment, evaluating sucking and swallowing, reviewing the infant's weight trajectory and output, and exploring relevant maternal health and birth history. Where indicated, the assessment should also consider oral function, prematurity, illness, developmental factors and other possible contributors. Anatomical findings should be interpreted in the context of function, rather than treated as a diagnosis in isolation (Geddes et al., 2008; Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3, 2023). The plan should therefore address both the immediate consequences and the underlying cause. This might mean supporting expression while working on attachment, assessing oral function where appropriate, reviewing a possible medical contributor, or arranging referral to another professional. The approach should be collaborative, with clear explanations, realistic options and a review point to establish whether milk transfer, infant intake and the lactating person's goals are being supported. Families should not be left with a long-term expressing plan without a clear explanation of why the infant is struggling to transfer milk or what is being done to address it. Equally, investigation of the cause should not delay measures needed to protect infant nutrition or milk production. An International Board Certified Lactation Consultant (IBCLC) or another appropriately qualified infant-feeding professional can help assess feeding and lactation, coordinate support and identify when further medical assessment is needed. The appropriate pathway depends on the concerns identified and the professional's scope of practice. See your articles on the roles of an IBCLC and what an infant-feeding specialist does for further information. Protecting the opportunity to breastfeed Protecting breast milk production is not about achieving a particular feeding pattern or requiring every family to pursue exclusive breastfeeding. It is about understanding how milk production responds to removal, recognising when an infant is not transferring milk effectively and making informed decisions that support both infant intake and the lactating person's goals. Where an infant cannot remove milk effectively, timely support may help maintain production while the cause is assessed. This may involve direct feeding support, expressing, supplementation or a combination of approaches. The specific plan should reflect the infant's needs, the lactating person's circumstances and the feeding goals of the family. The central principle is that milk production and milk transfer must be considered together, without assuming they are the same problem. Understanding the physiology makes it easier to identify where support is needed, avoid relying on interventions that do not address the underlying difficulty, and review whether the plan is achieving its intended purpose. References Becker, G.E., Smith, H.A. and Cooney, F. (2022) ‘Methods of milk expression for lactating women’, Cochrane Database of Systematic Reviews, 2022(9), CD006170. doi: 10.1002/14651858.CD006170.pub5. Breastmilk Ecology: Genesis of Infant Nutrition Working Group 3 (2023) ‘Infant factors that impact the ecology of human milk secretion and composition—a report from “Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)” Working Group 3’, The American Journal of Clinical Nutrition, 117(Suppl. 1), pp. S43–S60. doi: 10.1016/j.ajcnut.2023.04.018. Brodribb, W. (2018) ‘ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018’, Breastfeeding Medicine, 13(5), pp. 307–314. doi: 10.1089/bfm.2018.29092.wjb. Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only’, Early Human Development, 84(7), pp. 471–477. doi: 10.1016/j.earlhumdev.2007.12.008. Kellams, A. et al. (2017) ‘ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017’, Breastfeeding Medicine, 12(3), pp. 188–198. doi: 10.1089/bfm.2017.29038.ajk. Neville, M.C. and Morton, J. (2001) ‘Physiology and endocrine changes underlying human lactogenesis II’, The Journal of Nutrition, 131(11), pp. 3005S–3008S. doi: 10.1093/jn/131.11.3005S. National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194 NHS (n.d.) Milk supply. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/breastfeeding-challenges/milk-supply/ Pang, W.W. and Hartmann, P.E. (2007) ‘Initiation of human lactation: secretory differentiation and secretory activation’, Journal of Mammary Gland Biology and Neoplasia, 12(4), pp. 211–221. doi: 10.1007/s10911-007-9054-4. Slater, C.N. and Spatz, D.L. (2025) ‘Guidelines for primary pediatric care professionals to help patients establish and protect milk supply’, MCN: The American Journal of Maternal/Child Nursing, 50(4), pp. 192–203. doi: 10.1097/NMC.0000000000001107. Spatz, D.L. et al. (2025) ‘Proactive management of lactation in the birth hospital to ensure long-term milk production and sustainable breastfeeding’, Journal of Midwifery & Women's Health, 70(2), pp. 343–349. doi: 10.1111/jmwh.13726. World Health Organization (1998) Relactation: Review of Experience and Recommendations for Practice. Geneva: World Health Organization.

The International Code of Marketing of Breast-milk Substitutes, usually called the WHO Code, was introduced to protect infant and young child health by addressing the way breast-milk substitutes and related products are marketed. It recognises that commercial promotion can influence feeding decisions and that families need accurate, independent information to make informed choices about how they feed their babies (WHO, 1981). Although the Code was adopted more than four decades ago, inappropriate marketing remains a public-health concern. Understanding why it was created, how marketing has changed and what it means for healthcare professionals helps explain why the Code remains relevant today. Why the Code was introduced Breastfeeding has long been recognised as important for infant health, but the expansion of commercial infant formula marketing during the twentieth century changed the environment in which families made feeding decisions. As manufactured milk products became more widely available, companies increasingly promoted them as modern, convenient or desirable alternatives to breastfeeding. These developments took place alongside wider social changes. Changing expectations around household hygiene, the convenience of feeding and the growth of manufactured milk products all influenced infant-care practices. Commercial promotion contributed to the perception that manufactured products could offer a straightforward alternative to breastfeeding. However, access to clean water, adequate sanitation and reliable supplies was not universal, creating particular risks where formula was prepared in unsafe conditions. Concerns grew about marketing practices in lower-income countries, where advertising could encourage families to use products that were expensive and potentially difficult to prepare safely. Breastfeeding advocates, healthcare professionals and public-health campaigners challenged manufacturers' promotional practices and raised concerns about the consequences for infant health. The Nestlé boycott became an important part of this history. Campaigners in the United States initiated a boycott of Nestlé products in 1977, drawing attention to the marketing of infant formula in countries where families could face significant barriers to its safe use. The controversy helped bring international attention to the influence of commercial promotion on infant-feeding decisions. The campaign was part of a wider movement involving many organisations and advocates; it was not the sole cause of the WHO Code. In 1979, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) convened an international meeting on infant and young child feeding. The meeting called for the development of an international code to regulate the marketing of breast-milk substitutes. Following further work, the International Code of Marketing of Breast-milk Substitutes was adopted by the World Health Assembly on 21 May 1981, with 118 votes in favour (WHO, 1981). The Code established an international framework intended to protect breastfeeding and ensure that breast-milk substitutes, when necessary, were used appropriately and on the basis of adequate information. It also recognised that marketing should not undermine breastfeeding or exploit the trust families place in healthcare professionals. What the Code covers The Code addresses the marketing of breast-milk substitutes, including infant formula, as well as feeding bottles and teats. Its scope also includes products marketed or represented as suitable to replace breast milk, depending on their intended use and the relevant provisions of the Code and subsequent World Health Assembly resolutions. The Code is not limited to the wording of an advertisement. It considers the wider methods through which products are promoted, including free samples, gifts, sponsorship, promotional materials, contact with healthcare workers and the use of healthcare settings to market products. The Code also sits within a wider framework of subsequent World Health Assembly resolutions, which clarify and strengthen aspects of its implementation as marketing practices and infant-feeding products have changed. The underlying principle is that commercial interests should not interfere with families' access to impartial infant-feeding information or with the protection, promotion and support of breastfeeding (WHO, 1981; WHO, 2008). How the Code is undermined today Although the WHO Code was adopted in 1981, inappropriate marketing of breast-milk substitutes remains a global public-health concern. Reports continue to document practices that conflict with the Code, including misleading claims, promotion through healthcare professionals, digital advertising and the use of branding to build consumer recognition and loyalty (WHO and UNICEF, 2022; WHO and UNICEF, 2024; WHO, 2026). The problem is not simply that individual advertisements occasionally cross a line. Establishing brand recognition and loyalty can have commercial value beyond a single purchase. When a brand becomes familiar during pregnancy, is associated with professional education or appears repeatedly in parenting content, that familiarity may influence later purchasing decisions. The effectiveness of restrictions depends on the strength of legislation, monitoring, enforcement and penalties. Where fines are outweighed by the commercial benefits of continued marketing, including the long-term value of brand recognition and consumer loyalty, penalties may do little to deter repeat practices. This creates a concerning incentive for companies to continue marketing in ways that undermine the Code, particularly where enforcement is inconsistent (WHO and UNICEF, 2024; WHO, 2026). Marketing has also become less straightforward to recognise. It may appear through social media influencers, sponsored parenting content, online feeding advice, professional publications, educational events and brand-linked resources. Some content is overtly promotional; other material may appear independent while directing attention towards a particular manufacturer or product. This can blur the boundary between education and advertising (WHO, 2022a; WHO and UNICEF, 2022; First Steps Nutrition Trust, 2019; First Steps Nutrition Trust, 2025). Less transparent or underhand marketing can use educational content, professional endorsements, influencer recommendations, sponsored events or apparently independent advice to create favourable associations with a brand. These practices raise questions about transparency, commercial interests and whether families can distinguish independent information from promotion. The Code is therefore relevant beyond obvious advertisements. A product does not need to be directly recommended for commercial influence to affect how it is perceived. Repeated exposure to a logo, branded product or company-associated message can make a manufacturer seem familiar, trustworthy or professionally endorsed. The UK legal position The WHO Code is an international public-health standard. It is not, by itself, a single piece of UK legislation that makes every provision directly enforceable in the same way. The UK has introduced legislation that gives effect to some, but not all, of the Code's provisions and subsequent resolutions. The relevant legal framework includes regulations governing infant formula and follow-on formula, with related provisions for foods for special medical purposes. The broad regulatory approach is similar across the UK, but the legal instruments and administrative arrangements are not identical. Infant formula legislation is devolved: England, Scotland and Wales have their respective arrangements, while EU nutrition legislation continues to apply in Northern Ireland under the Windsor Framework (Department of Health and Social Care, 2024). UK law does not implement every aspect of the WHO Code. Some forms of marketing and advertising that are inconsistent with the Code's wider recommendations may still be permitted under UK regulations. The Baby Feeding Law Group UK and First Steps Nutrition Trust have highlighted gaps between the Code and the UK regulatory position, including concerns about the marketing of particular infant milk products (Baby Feeding Law Group UK, 2004; Baby Feeding Law Group UK, 2022; First Steps Nutrition Trust, 2024; Institute of Health Visiting, 2024). The distinction matters: a marketing practice may be inconsistent with the WHO Code without necessarily constituting a breach of UK law. Equally, compliance with the minimum legal requirements does not automatically mean that a practice meets the wider professional responsibilities associated with working within the Code. Healthcare professionals should understand the law relevant to their work, alongside their professional standards, employer policies and any additional requirements associated with their service or accreditation. What the Code means for professionals The WHO Code is not simply a voluntary marketing preference for professionals to consider when convenient. It establishes an international public-health standard, and the WHO has published specific guidance explaining the responsibilities of health workers in protecting families from inappropriate promotion of breast-milk substitutes (WHO, 2020). The Code and relevant subsequent World Health Assembly resolutions should inform professional practice, including decisions about educational resources, commercial relationships, public-facing content and the products displayed in healthcare environments. Professionals should understand both the Code's principles and the legal requirements that apply to their work. For midwives and nurses registered with the Nursing and Midwifery Council (NMC), the NMC Code requires professionals to practise with integrity, use the best available evidence, preserve safety and promote trust in the profession. These duties are relevant when considering commercial influence, conflicts of interest and the information shared with families (NMC, 2018). For International Board Certified Lactation Consultants (IBCLCs), the Code of Professional Conduct explicitly requires adherence to the principles and aims of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions. This makes the relationship between the WHO Code and professional conduct particularly direct for IBCLCs (IBLCE, 2023). Professionals working in UNICEF UK Baby Friendly-accredited services are also expected to work within the Code and subsequent resolutions as part of the standards underpinning accreditation. The UNICEF UK Baby Friendly Initiative provides guidance to help health workers apply the Code in day-to-day practice (UNICEF UK Baby Friendly Initiative, 2025). Other professional bodies, employers and organisations may have additional policies that apply to their members or staff. Healthcare professionals and the Code The WHO Code is relevant to all health workers who have contact with babies and families, not only those who specialise in infant feeding. This includes health visitors, midwives, nurses, IBCLCs, doctors, dietitians, pharmacists and other professionals involved in supporting infant feeding (WHO, 2020; UNICEF UK Baby Friendly Initiative, 2025). The Lactation Consultants of Great Britain’s Who’s Who in Breastfeeding Support and Lactation in the UK resource explains the differences between breastfeeding support roles. For a further overview of the work of an infant-feeding specialist, see What does an infant feeding specialist do?. Health visitors have a particularly important role because they often provide ongoing support to families in the community, including discussions about feeding, growth, milk supply and the introduction of formula. The information they share, the resources they distribute and the products displayed or recommended in their working environments can influence family decisions. For health visitors who are registered nurses or midwives, the NMC Code sets professional expectations around evidence-based practice, integrity and maintaining public trust (NMC, 2018). Services working towards or maintaining UNICEF UK Baby Friendly accreditation also have specific expectations for implementing the WHO Code in health visiting and community settings (UNICEF UK Baby Friendly Initiative, 2025). IBCLCs have an explicit professional obligation: the IBCLC Code of Professional Conduct requires adherence to the principles and aims of the WHO Code and relevant subsequent World Health Assembly resolutions (IBLCE, 2023). In everyday practice, healthcare professionals should: Provide accurate, evidence-based and impartial infant-feeding information, without allowing commercial interests to influence their advice. Avoid displaying or distributing promotional materials for breast-milk substitutes, feeding bottles, teats or other products covered by the Code. Scrutinise manufacturer-funded education, sponsored events, gifts, free products and other commercial relationships for conflicts of interest or the appearance of endorsement. Use appropriately referenced educational materials and consider whether branded images, logos or product placement introduce unnecessary commercial promotion. Challenge misleading claims and seek advice from their employer, professional body or relevant service lead when unsure how to respond to a potential breach. These responsibilities do not mean withholding information about formula or judging families who use it. Families need practical, compassionate support whatever their feeding circumstances. The professional duty is to provide that support without inappropriate commercial influence and to protect families' ability to make informed decisions. Imagery, branding and endorsement The Code restricts advertising and promotion of products within its scope to the public. For professionals, applying its principles means looking carefully at how products are represented in clinical and educational settings. A branded feeding bottle, teat, formula container or manufacturer's logo in a public-facing photograph may give a product or company additional visibility. A professional's photograph beside a product, a testimonial, a recommendation or the display of a manufacturer's materials may also be interpreted as an endorsement, even when no explicit endorsement was intended. The context matters. A branded image used to explain safe bottle-feeding technique is not necessarily equivalent to a branded promotional image. An unbranded image used to demonstrate safe bottle-feeding can communicate the practical information without giving additional visibility to a commercial product. Professionals must be able to provide practical, factual information about bottle feeding and formula use without turning that information into advertising. The aim is not to make formula feeding invisible or to make families feel judged. It is to separate necessary, balanced information from avoidable brand promotion. The same scrutiny applies to presentations, websites, leaflets, study days and social media. Professionals should consider whether an image is necessary, whether it introduces avoidable brand exposure, whether the information is balanced and whether the content could influence families through commercial associations rather than evidence. The UNICEF UK Baby Friendly Initiative's guide for health workers and First Steps Nutrition Trust's reports on marketing to healthcare professionals provide practical guidance for identifying these issues (UNICEF UK Baby Friendly Initiative, 2025; First Steps Nutrition Trust, 2019). Sponsorship, gifts and commercial relationships Commercial relationships can influence professional environments in ways that are not always immediately obvious. Sponsorship of education, provision of free products, gifts, promotional resources and manufacturer-funded events can create a connection between a company and the professional or service receiving the benefit. Even where a professional believes that a gift or sponsorship has not influenced their judgement, it may create a perception of endorsement. It can also give a company access to professional networks or opportunities to present its products as familiar, trusted or associated with clinical expertise. Working within the Code means critically evaluating these relationships. Professionals should avoid accepting gifts, free samples or benefits that conflict with the Code or applicable professional standards, and should not allow manufacturers to use professional roles, credentials or healthcare settings to promote products inappropriately. Educational content funded by manufacturers should be assessed carefully for accuracy, balance, transparency and commercial influence. Information described as scientific or factual should be scrutinised rather than accepted simply because it is presented in a professional setting (First Steps Nutrition Trust, 2019). Professional independence requires more than disclosing a commercial relationship after it has occurred. It requires considering whether the relationship is appropriate in the first place and whether it could undermine trust in the advice provided. Professional duty and independence Working within the WHO Code should be understood as part of professional responsibility, not merely an optional organisational preference. Professionals have a duty to maintain public trust, use independent evidence and protect families from inappropriate commercial influence. Where a professional code explicitly incorporates the WHO Code, adherence is also a requirement of that professional standard. For further information about the professional role and scope of an IBCLC, see Roles of an IBCLC. This means critically evaluating manufacturer-funded education, declining arrangements that compromise independence, using appropriately referenced information and challenging misleading or inappropriate marketing when it is identified. It also means ensuring that families who use formula receive accurate preparation advice, practical feeding support and compassionate care without being exposed to unnecessary promotion. The Code does not mean that professionals must withhold information about formula, nor does it prevent clinically appropriate discussion of products. It requires a distinction between providing the information families need and promoting commercial interests. Ultimately, professional independence is not demonstrated simply by believing that a particular brand has not influenced one's judgement. It requires active consideration of how sponsorship, branding, gifts, repeated exposure and commercial relationships might influence professional behaviour or public perception. The responsibility is to ensure that infant-feeding advice remains grounded in evidence, the needs of the baby and the circumstances of the family. Supporting families without judgement Protecting families from inappropriate marketing must go hand in hand with providing compassionate, practical infant-feeding support. Families may breastfeed, use formula or combine feeding methods for a range of personal, medical and practical reasons. They should be able to access accurate information and skilled support without judgement. Working within the Code does not mean withholding information about formula, making assumptions about a family's feeding decisions or suggesting that families who use breast-milk substitutes have done something wrong. It means ensuring that information is provided because it meets the family's needs, rather than because it benefits a manufacturer. Families need reliable information about feeding options, safe preparation, responsive feeding and how to recognise when further support is needed. That information should be evidence-based, clearly referenced and free from inappropriate commercial influence. The WHO Code remains relevant because the way products are marketed can shape the information families encounter before they ever speak to a healthcare professional. Upholding the Code is therefore a shared responsibility across healthcare, public health, professional education and the wider infant-feeding environment. References Baby Feeding Law Group UK (2004) Clarifying misconceptions about the UK law on the marketing of infant formula: BFLG UK briefing document. Available at: https://www.bflg-uk.org/our-work#reports Baby Feeding Law Group UK (2022) Infant milks marketed as foods for special medical purposes (FSMP): The case for regulatory reform to protect infant health. Available at: https://www.bflg-uk.org/our-work#guidance Department of Health and Social Care (2024) Nutrition legislation information sheet. Available at: https://www.gov.uk/government/publications/nutrition-legislation-information-sources/nutrition-legislation-information-sheet--2 First Steps Nutrition Trust (2019) Scientific and factual? A further review of breastmilk substitute advertising to healthcare professionals. London: First Steps Nutrition Trust. Available at: https://www.firststepsnutrition.org/reviews-of-claims First Steps Nutrition Trust (2024) Regulations for infant formula marketed in the UK. June 2024. Available at: https://infantmilkinfo.org/wp-content/uploads/2024/06/RegulationsinfantformulaJune2024.pdf First Steps Nutrition Trust (2025) Current formula marketing practices in the UK: Why stronger rules are needed. Published 17 July 2025. London: First Steps Nutrition Trust. Information available at: https://www.firststepsnutrition.org/august-2025 Institute of Health Visiting (2024) ‘Baby Feeding Law Group UK: Misconceptions about the UK law on the marketing of infant formula’, 26 January. Available at: https://ihv.org.uk/news-and-views/news/baby-feeding-law-group-uk-misconceptions-about-the-uk-law-on-the-marketing-of-infant-formula/ International Board of Lactation Consultant Examiners (IBLCE) (2023) Code of Professional Conduct for IBCLCs. Updated 1 May 2023. Available at: https://ibclc-commission.org/wp-content/uploads/2023/05/2023May1Code-of-Professional-ConductFINAL.pdf Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC. Available at: https://www.nmc.org.uk/standards/code/ UNICEF UK Baby Friendly Initiative (2025) The International Code of Marketing of Breastmilk Substitutes: A guide for health workers. Updated November 2025. Available at: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/international-code-marketing-breastmilk-substitutes-resources/guide-to-working-within-the-code/ World Health Organization (WHO) (1981) International Code of Marketing of Breast-milk Substitutes. Geneva: WHO. Available at: https://iris.who.int/bitstream/handle/10665/40382/9241541601.pdf?sequence=1 World Health Organization (WHO) (2008) The International Code of Marketing of Breast-milk Substitutes: Frequently asked questions—updated version 2008. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789241594295 World Health Organization (WHO) (2020) The International Code of Marketing of Breast-milk Substitutes: Frequently asked questions on the roles and responsibilities of health workers. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789240005990 World Health Organization (WHO) (2022a) Scope and impact of digital marketing strategies for promoting breast-milk substitutes. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789240046085 World Health Organization (WHO) and UNICEF (2022) How the marketing of formula milk influences our decisions on infant feeding. Geneva: WHO and UNICEF. Available at: https://www.who.int/publications/i/item/9789240044609 World Health Organization (WHO) and UNICEF (2024) Marketing of breast-milk substitutes: national implementation of the International Code, status report 2024. Geneva: WHO and UNICEF. Available at: https://www.who.int/publications/i/item/9789240094482 World Health Organization (WHO) (2026) Marketing of breast-milk substitutes: national implementation of the International Code, status report 2026. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789240122758

Tongue-tie, also known as ankyloglossia, has been recognised for centuries, but its definition, clinical significance and management continue to be debated. Although the condition is often described in terms of a short or tight lingual frenulum, the appearance of the tissue alone does not establish whether tongue movement is functionally restricted (Mills et al., 2019a). Understanding tongue-tie involves more than examining the tissue beneath the tongue. Its development begins before birth, and variation in anatomy may reflect a combination of genetic and developmental influences. However, the precise causes of tongue-tie remain incompletely understood. This article explores the historical development of tongue-tie treatment, the embryological development of the tongue and lingual frenulum, and the evidence concerning possible genetic, familial and environmental influences. What is a 'tongue-tie'? The lingual frenulum is a normal anatomical structure beneath the tongue. It is not simply a discrete string or band that exists independently of the surrounding tissues. Anatomical research has demonstrated that it is formed by a dynamic fold of oral mucosa and the underlying fascia of the floor of the mouth. Its appearance changes as the tongue moves, and its thickness and composition vary between individuals (Mills et al., 2019a; Mills et al., 2019b; Mills et al., 2020). Ankyloglossia is a clinical diagnosis in which the lingual frenulum is considered to restrict tongue mobility. The distinction is important: everyone has a lingual frenulum, but not everyone has a tongue-tie that restricts function. Research has also highlighted the limitations of classifying tongue-tie by visual appearance alone, because the relationship between the appearance of the frenulum and functional restriction is not straightforward (Mills et al., 2019a). The term tongue-tie is therefore best understood in relation to function, rather than as a description of every variation in frenulum appearance. Historical development of tongue-tie treatment Biblical period One frequently cited historical reference appears in the Gospel of Mark. Mark 7:35 describes a man's tongue being loosened, after which he was able to speak plainly. This passage has been discussed in relation to tongue-tie, although the biblical account does not establish that the man had ankyloglossia (Levy, 1995). 5th–4th century BCE Hippocrates is associated with the early Greek medical tradition in which anatomical conditions were considered in relation to health and function. Historical accounts trace the discussion of tongue restriction and its treatment to ancient medicine. Accounts of early cutting methods describe variation in the materials and instruments used, including references to blades such as axe blades and in some countries; sharp-edged leaves. These accounts sit alongside the broader history of early practices for releasing tissue beneath the tongue. 1st century CE The Roman physician Aulus Cornelius Celsus described a tongue attachment that could affect speech in De Medicina. His account included holding the tongue with forceps and incising the membrane beneath it. He warned of bleeding because of the blood vessels in the area and recognised that division would not necessarily resolve every speech difficulty (Celsus, De Medicina, Book VII, Chapter 12). Medieval period Historical accounts describe midwives using their fingernails to release the tissue beneath the tongue, while surgeons used cutting instruments. These practices reflected the different roles of midwives and surgeons at the time (Obladen, 2010). 16th–17th centuries Surgical texts and illustrations documented a range of techniques, including holding the tongue forward while cutting the frenulum with a small knife, and using scissors or instruments to lift the tongue and expose the tissue. Some accounts describe midwives keeping a fingernail sharp to release the tongues of newborn babies. Such reports demonstrate that the practice existed, although they do not establish that it was universal (Ganesan, Girgis and Mitchell, 2019). 18th century Surgeons described instruments such as spatulas and grooved directors to lift the tongue and make the frenulum more accessible. These instruments helped practitioners visualise the tissue and control the incision, with the aim of avoiding injury to deeper structures. Bleeding remained a recognised complication (Ganesan, Girgis and Mitchell, 2019). 19th–early 20th centuries Tongue-tie division was undertaken for a range of perceived difficulties, including speech and feeding problems. In the early twentieth century, the procedure was reportedly performed routinely in some settings. As bottle-feeding became more common during the twentieth century, fewer infants depended on breastfeeding to receive their milk. This may have influenced how often tongue-tie was recognised as a potential feeding difficulty and whether division was considered. The historical literature describes a decline in tongue-tie division during this period, although changes in infant-feeding practices were only one possible influence (Ganesan, Girgis and Mitchell, 2019; Obladen, 2010). 1981 The World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes on 21 May 1981. The Code was developed in response to concerns about the promotion of breast-milk substitutes and declining breastfeeding. Its aim is to protect and support breastfeeding while ensuring that breast-milk substitutes are available and appropriately used when needed. Its scope includes breast-milk substitutes, feeding bottles and teats (World Health Organization, 1981). The Code was not a tongue-tie treatment guideline, but it forms part of the wider history of infant-feeding policy and the protection of breastfeeding. Late 20th century to present As breastfeeding support and awareness increased, interest in the possible effects of restricted tongue movement on feeding also returned. Tongue-tie division again became a subject of clinical discussion and research. Contemporary assessment places greater emphasis on whether the frenulum restricts tongue function and whether this is associated with difficulties for the individual feeding dyad, rather than relying on appearance alone. The presence of a lingual frenulum is normal anatomy; the clinical question is whether its structure and movement are associated with meaningful functional restriction (Mills et al., 2019a; Ganesan, Girgis and Mitchell, 2019). 2019 On 8 February 2019, the Care Quality Commission (CQC) confirmed that frenulotomy carried out by, or under the supervision of, a healthcare professional falls within the regulated activity of surgical procedures. Providers carrying on this regulated activity are legally required to register with CQC. Registration is a statutory obligation, not an optional accreditation (Care Quality Commission, 2019). This forms part of the modern regulatory framework for tongue-tie division in independent healthcare settings in England. Embryological development of the tongue and lingual frenulum The tongue begins developing during the fourth week of gestation, through a complex process involving tissues associated with the pharyngeal arches. The anterior two-thirds and posterior third of the tongue have different embryological origins, and development involves coordinated changes in tissue growth, differentiation and organisation (Nie, 2005). Historically, tongue-tie was explained by the theory that incomplete apoptosis during embryological development prevented the tissues beneath the tongue from separating fully. Apoptosis is programmed cell death, a normal process involved in embryonic development. Under this proposed mechanism, tissue that would ordinarily regress was thought to persist beneath the tongue, restricting its movement. Although this explanation continues to appear in medical literature, it is a traditional developmental hypothesis rather than an established cause of human ankyloglossia. More recent anatomical research has challenged the concept of the lingual frenulum as a discrete remnant of tissue that failed to disappear. Instead, the frenulum has been described as a dynamic, three-dimensional fold of oral mucosa and underlying floor-of-mouth fascia, whose appearance changes with tongue movement. As the tongue elevates or retracts, tension and movement within these tissues draw them into a midline fold (Mills et al., 2019a; Mills et al., 2019b; Mills et al., 2020). This dynamic model offers a different anatomical framework from the older explanation based on incomplete tissue separation. It also raises questions about how tissue development, individual anatomical variation and mechanical forces may interact during development. Fetal movement is part of normal development, but the precise contribution of movement and mechanical forces to the formation of the lingual frenulum, and to the restricted mobility experienced by some individuals, has not been established. The lingual frenulum is therefore best understood in the context of the wider structures beneath the tongue, rather than as an isolated band whose appearance alone determines function. Research has demonstrated variation in its morphology, while the relationship between individual anatomical features and functional restriction remains incompletely understood (Mills et al., 2019a; Mills et al., 2019b). Although apoptosis is a recognised biological process, evidence that it occurs during tongue development does not establish incomplete apoptosis as the cause of tongue-tie. The precise developmental mechanisms underlying ankyloglossia remain uncertain, and further research is needed to clarify how embryological processes, tissue organisation and mechanical influences may contribute. Tongue-tie, palate development, sleep and neurodivergence Tongue posture plays a role in the development of the palate. Where tongue movement is restricted, this may affect how the tongue rests against the roof of the mouth during development. Research has identified an association between a short lingual frenulum, a high-arched palate and obstructive sleep apnoea in children (Camañes-Gonzalvo et al., 2024). A high-arched palate and other differences in oral and facial structure may be relevant to upper-airway function and sleep. Sleep-disordered breathing can disrupt sleep and affect attention, behaviour and emotional regulation. These effects may overlap with features of attention-deficit/hyperactivity disorder (ADHD), and sleep difficulties are also reported in neurodivergent children. Won et al. (2017) discussed these possible relationships in a clinical case involving a child with ADHD symptoms and obstructive sleep apnoea. However, although links between tongue-tie, palate shape, sleep and neurodevelopment are being investigated, the evidence does not establish that tongue-tie causes ADHD or neurodivergence. Further research is needed to understand how these factors may be related. Genetic and familial influences Tongue-tie can occur in isolation, but familial patterns have also been reported. This has led researchers to investigate whether genetic factors contribute to its development. A pedigree study involving 149 patients reported familial clustering and suggested a possible X-linked pattern of inheritance in some cases. The study provides evidence that genetic influences may be relevant, but its findings should not be interpreted as demonstrating that all tongue-tie is inherited in the same way (Klockars and Pitkäranta, 2009; A study on the genetic inheritance of ankyloglossia based on pedigree analysis, 2012). Ankyloglossia has also been described in association with certain uncommon genetic syndromes, including X-linked cleft palate syndrome. However, most people with tongue-tie do not have a recognised congenital syndrome (StatPearls, 2023). The available evidence is consistent with genetic influences contributing to at least some cases, but the inheritance patterns, genes involved and interactions with other developmental factors are not fully established. A family history may therefore be relevant without being necessary for tongue-tie to occur. Gender differences Several studies and clinical reviews report that tongue-tie is diagnosed more frequently in males than females. However, reported prevalence varies considerably between studies, partly because researchers and clinicians use different definitions and diagnostic criteria (StatPearls, 2023; Shivji, Chandrasekara and Ria, 2026). Differences in reported prevalence do not, on their own, establish the biological explanation for the sex difference. Genetic influences, including possible sex-linked inheritance in some families, have been proposed, but the evidence does not establish one mechanism that explains all cases. It is also important to consider ascertainment: differences in who is assessed, which diagnostic criteria are used and whether studies include newborns or older children can influence the reported sex ratio. The apparent difference should therefore be interpreted in the context of each study rather than as a universal rule. Folic acid and the proposed association with tongue-tie Folic acid supplementation before conception and during early pregnancy is recommended because it reduces the risk of neural tube defects. Concerns have circulated that folic acid supplementation might increase the likelihood of tongue-tie, partly following a hypothesis proposed in a 2020 study. That case-control study reported an association between regular preconception folic acid use and tongue-tie in the infants studied. However, an association in a single observational study does not establish causation, and the study had methodological limitations (Amitai et al., 2020). A systematic review published in 2023 examined the available evidence and found only one directly relevant study. The reviewers concluded that the evidence was insufficient to establish a relationship between maternal folic acid supplementation and ankyloglossia. They also found no research evidence establishing a mechanism by which supplementation would cause tongue-tie (Rubin et al., 2023). The proposed association must therefore be treated as an unconfirmed hypothesis, not an established cause. The known benefits of folic acid supplementation in preventing neural tube defects substantially outweigh the unproven concern about tongue-tie. People planning a pregnancy or who may become pregnant should continue to follow current UK recommendations on folic acid. A multifactorial explanation remains possible The available evidence does not establish one cause that explains every case of tongue-tie. Developmental processes, variation in tissue formation and genetic influences may all be relevant, but the relative contribution of each remains uncertain. It is also important to separate the development of a frenulum from the question of whether it restricts function. A visible frenulum, a particular attachment point or a family history cannot independently determine the functional significance of the tissue. Anatomical assessment needs to be considered alongside tongue mobility and the individual’s functional presentation (Mills et al., 2019a; Mills et al., 2020). Research continues to examine the relationship between frenulum anatomy, tongue movement and clinical outcomes. Better understanding of these relationships may help clarify why some individuals experience functional restriction while others with a similar-looking frenulum do not. Conclusion Tongue-tie has a long history, from early descriptions of tongue restriction and surgical division to contemporary discussion of feeding function, anatomy and clinical oversight. Although proposed explanations include altered embryological development and genetic influences, the precise causes of ankyloglossia remain incompletely understood. Current anatomical research demonstrates that the lingual frenulum is a dynamic structure with considerable variation between individuals. Its appearance alone does not establish whether it restricts tongue movement. A careful distinction between anatomical variation, functional restriction and proposed causes is therefore essential when interpreting the evidence. Further research into embryological development, genetic influences and the relationship between anatomy and function will be important in improving understanding of this condition. References Amitai, Y., Shental, H., Atkins-Manelis, L., Koren, G. and Stein Zamir, C. (2020) ‘Pre-conceptional folic acid supplementation: A possible cause for the increasing rates of ankyloglossia’, Medical Hypotheses, 134, 109508. https://doi.org/10.1016/j.mehy.2019.109508 Camañes-Gonzalvo, S., Montiel-Company, J.M., Paredes-Gallardo, V., Puertas-Cuesta, F.J., Marco-Pitarch, R., García-Selva, M., Bellot-Arcís, C. and Casaña-Ruiz, M.D. (2024) ‘Relationship of ankyloglossia and obstructive sleep apnea: systematic review and meta-analysis’, Sleep and Breathing, 28(3), pp. 1067–1078. https://doi.org/10.1007/s11325-024-03021-4 Celsus, A.C. (1938) De Medicina. Book VII, Chapter 12. Translated by W.G. Spencer. Cambridge, MA: Harvard University Press. Available at: https://penelope.uchicago.edu/Thayer/E/Roman/Texts/Celsus/7*.html Care Quality Commission (2019) ‘Briefing for providers: Registration requirements for tongue-tie procedures’. Available at: https://www.cqc.org.uk/news/providers/briefing-providers-tongue-tie Ganesan, K., Girgis, S. and Mitchell, S. (2019) ‘Lingual frenotomy in neonates: past, present, and future’, British Journal of Oral and Maxillofacial Surgery, 57(3), pp. 207–213. https://doi.org/10.1016/j.bjoms.2019.03.004 Klockars, T. (2007) ‘Familial ankyloglossia (tongue-tie)’, International Journal of Pediatric Otorhinolaryngology, 71(8), pp. 1321–1324. https://doi.org/10.1016/j.ijporl.2007.05.018 Klockars, T. and Pitkäranta, A. (2009) ‘Inheritance of ankyloglossia (tongue-tie)’, Clinical Genetics, 75(1), pp. 98–99. https://doi.org/10.1111/j.1399-0004.2008.01096.x Levy, P.A. (1995) ‘Tongue-tie: Management of a short sublingual frenulum’, Pediatrics in Review, 16(9), pp. 345–346. https://doi.org/10.1542/pir.16-9-345 Mills, N., Pransky, S.M., Geddes, D.T. and Mirjalili, S.A. (2019a) ‘What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum’, Clinical Anatomy, 32(6), pp. 749–761. https://doi.org/10.1002/ca.23343 Mills, N., Keough, N., Geddes, D.T., Pransky, S.M. and Mirjalili, S.A. (2019b) ‘Defining the anatomy of the neonatal lingual frenulum’, Clinical Anatomy, 32(6), pp. 824–835. https://doi.org/10.1002/ca.23410 Mills, N., Geddes, D.T., Amirapu, S. and Mirjalili, S.A. (2020) ‘Understanding the lingual frenulum: Histological structure, tissue composition, and implications for tongue tie surgery’, International Journal of Otolaryngology, 2020, Article 1820978. https://doi.org/10.1155/2020/1820978 Nie, X. (2005) ‘Apoptosis, proliferation and gene expression patterns in mouse developing tongue’, Anatomy and Embryology, 210(2), pp. 125–132. https://doi.org/10.1007/s00429-005-0009-5 Obladen, M. (2010) ‘Much ado about nothing: Two millennia of controversy on tongue-tie’, Neonatology, 97(2), pp. 83–89. https://doi.org/10.1159/000235682 Rubin, G., Stewart, C., McGowan, L., Woodside, J.V., Barrett, G., Godfrey, K.M. and Hall, J. (2023) ‘Maternal folic acid supplementation and the risk of ankyloglossia (tongue-tie) in infants; a systematic review’, PLOS ONE, 18(11), e0294042. https://doi.org/10.1371/journal.pone.0294042 Shivji, S., Chandrasekara, B. and Ria, B. (2026) ‘Tongue-ties: A review’, British Dental Journal, 240(1), pp. 27–32. https://doi.org/10.1038/s41415-025-9101-9 Walsh, J. and Benoit, M.M. (2019) ‘Ankyloglossia and other oral ties’, Otolaryngologic Clinics of North America, 52(5), pp. 795–811. https://doi.org/10.1016/j.otc.2019.06.008 World Health Organization (1981) International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9241541601 Won, D.C., Guilleminault, C., Koltai, P.J., Quo, S.D., Stein, M.T. and Loe, I.M. (2017) ‘It is just attention-deficit hyperactivity disorder…or is it?’, Journal of Developmental & Behavioral Pediatrics, 38(2), pp. 169–172. https://doi.org/10.1097/DBP.0000000000000386

Milk flow is part of the mechanics of infant feeding, but the speed at which milk reaches a baby’s mouth is not always matched to the speed at which that baby can comfortably suck, swallow and breathe. This can be relevant across different ways of feeding, including feeding directly at the breast, expressed human milk, infant formula and other methods of milk delivery. During breastfeeding, a forceful milk ejection reflex can produce a rapid initial flow. Oversupply can also contribute to a more forceful, pressurised flow, as milk production exceeds the baby’s needs and milk may be released in greater volume or with greater force. These are related but distinct factors: a forceful let-down does not necessarily mean that milk production is excessive (Johnson et al., 2020; Pearson-Glaze, 2025a). During bottle feeding, the flow rate of the teat, the position of the baby and the way milk is delivered can influence how quickly milk enters the mouth. Although these mechanisms differ, all methods of feeding require consideration of the baby’s ability to coordinate sucking, swallowing and breathing (Pados et al., 2015; Pados, 2021). Understanding the source of the flow matters because the appropriate response depends on what is happening for that particular baby and feeding dyad. Understanding fast milk flow Families may use ‘fast flow’ to describe milk that sprays or drips strongly when a baby releases the breast, a pronounced rush of milk at the beginning of a feed, or a baby who appears to struggle when milk starts flowing. During bottle feeding, the term may describe a teat that delivers milk more quickly than the baby can comfortably manage. Milk ejection is a normal physiological process involving oxytocin. Some babies adapt readily to a forceful let-down, while others may cough, splutter, gulp or repeatedly come off the breast as they attempt to manage the flow (Pearson-Glaze, 2025a; La Leche League GB, 2026). Fast flow and hyperlactation are not interchangeable terms. Hyperlactation, also called oversupply, describes milk production that exceeds the volume required by the infant or infants. A breastfeeding parent may experience a forceful initial flow without producing excessive amounts of milk overall. Equally, a family experiencing hyperlactation may notice a strong, pressurised flow alongside other signs, such as persistent breast fullness, leaking, discomfort or recurrent breast inflammation (Johnson et al., 2020; La Leche League GB, 2026). The Academy of Breastfeeding Medicine emphasises that hyperlactation needs to be assessed in context. Individual signs, such as leaking or a baby feeding frequently, are not enough on their own to establish the diagnosis. Management should reflect the circumstances of the feeding dyad and the likely cause of the excess production (Johnson et al., 2020). Possible signs during feeding A baby managing a fast flow may: Cough, splutter or gulp during feeding. Pull away from the breast or repeatedly come on and off. Swallow rapidly or appear overwhelmed when milk begins to flow. Leak milk from the mouth or struggle to coordinate sucking, swallowing and breathing. Take a substantial volume of milk in a relatively short time. Become fussy, cry or appear uncomfortable during or after feeding. Experience trapped wind, frequent burping or apparent abdominal discomfort. Tire quickly or struggle to sustain feeding. Vomit, posset frequently or show reflux-like behaviour. Some breastfeeding parents may also notice persistent breast fullness, leaking, discomfort or recurrent plugged ducts when oversupply is present. In some cases, infant weight gain or stool patterns may provide additional information for the assessment (Johnson et al., 2020; La Leche League GB, 2026; Pearson-Glaze, 2025a, 2025b). These signs can be associated with fast flow or oversupply, but none establishes either as the cause. A baby taking large volumes may be responding to the way milk is delivered, but intake also depends on feeding frequency, individual appetite and the wider feeding pattern. Fussiness, wind, tiredness, vomiting and reflux-like behaviour can have several explanations. Coming off the breast may also relate to positioning, attachment, tiredness, distraction, nasal congestion, feeding cues or difficulties coordinating sucking, swallowing and breathing. Frequent feeding, short feeds and crying are common in early infancy and should not be treated as reliable stand-alone signs of oversupply (Johnson et al., 2020; La Leche League GB, 2026). Persistent coughing or choking, difficulty coordinating feeding, marked tiredness during feeds, repeated vomiting or concerns about growth warrant appropriate clinical assessment rather than an assumption that milk flow is responsible. Reflux symptoms can overlap with signs attributed to fast flow, and other causes may need to be considered (NHS, 2025; Johnson et al., 2020). Milk production, latch and milk transfer Milk production responds to hormonal processes and local regulation within the breast, as well as the frequency and effectiveness of milk removal. The relationship between feeding, milk transfer and production is therefore important when considering concerns about fast flow (Johnson et al., 2020; La Leche League GB, 2026). An ineffective latch or difficulty transferring milk can contribute to a baby feeding frequently or remaining at the breast for prolonged periods. In some circumstances, frequent feeding alongside additional milk expression or other factors that stimulate production may contribute to oversupply. However, this is not an inevitable outcome. Ineffective milk transfer can also result in inadequate breast stimulation and insufficient milk production. La Leche League GB notes that a shallow latch may occasionally contribute to oversupply when a baby feeds very frequently to obtain the volume they need, although inadequate milk removal is more likely to reduce production over time (La Leche League GB, 2026). Frequent feeding alone does not establish that a baby has an inefficient latch, nor does it prove that milk production is excessive. Frequent feeding can be entirely normal, particularly during periods of rapid growth or cluster feeding. Where feeding is difficult, it is important to distinguish between how much milk is being produced and how effectively the baby is transferring it. A baby may be feeding often because milk is readily available but difficult to manage; another may be feeding often because milk transfer is limited. These patterns can look similar to families but require different responses. A feeding assessment can consider positioning and attachment, swallowing, milk transfer, feeding duration, breast comfort, expressing practices, infant growth and the wider feeding history. It should also explore whether the baby appears to manage the flow comfortably rather than assuming that a particular behaviour identifies the cause. For further reading, see Increasing breast milk production and How to express breastmilk. When the pattern needs a broader view If there is ongoing breast or nipple pain, uncertainty about milk transfer, a baby who tires during feeds, persistent difficulty coordinating feeding or concerns about weight gain, a full feeding assessment is more useful than trying to change milk flow in isolation. Tongue function may be one consideration within that assessment, but anatomy alone cannot explain a feeding experience. Some infants with a visible lingual frenulum feed effectively, while other babies experience feeding difficulties for different or multiple reasons. Assessment should consider function alongside the feeding history and direct observation where appropriate. Systematic review evidence suggests that frenulotomy may improve maternal nipple pain in some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains limited (O’Shea et al., 2017). A report of fast flow should therefore not automatically lead to the assumption that a tongue-tie is present or responsible. The principle that anatomy provides information while function provides context is particularly relevant here. The aim is to understand what is affecting feeding, rather than attributing every difficulty to one feature. Further information is available in When feeding doesn’t feel right: looking beyond tongue-tie and Tongue-tie diagnosis and treatment: the importance of experienced infant feeding support. Managing fast flow during breastfeeding For a baby who is growing well and otherwise feeding comfortably, reassurance and careful observation may be all that is needed. Where milk flow appears to be contributing to difficulty, simple adjustments may help the baby manage feeding more comfortably. The most appropriate approach depends on whether the issue is a forceful initial let-down, ongoing oversupply, ineffective milk transfer or a combination of factors (Johnson et al., 2020; Pearson-Glaze, 2025a). Possible approaches include: Try a laid-back or reclined feeding position. Some breastfeeding parents find that allowing the baby to feed against the body in a more reclined position helps them manage a forceful flow. A more upright position or side-lying may suit some feeding dyads. Positioning should remain comfortable and allow the baby to breathe freely (La Leche League GB, 2026; Pearson-Glaze, 2025a). Allow the initial forceful flow to subside. If the baby repeatedly pulls away when milk first ejects, briefly detach them if needed and allow the strongest flow to pass before offering the breast again. Milk can be caught in a muslin cloth rather than deliberately collected in a device that applies suction or encourages additional milk removal (Pearson-Glaze, 2025a). Consider brief pre-feed expression when appropriate. If the initial flow is particularly forceful, a small amount of hand expression may help release the initial pressure until the strongest flow subsides. The aim is not to empty the breast or carry out a full expression, as repeated or substantial milk removal may stimulate further production. This approach will not be necessary for everyone and should be reviewed if it does not help (Johnson et al., 2020; La Leche League GB, 2026). Review milk-collecting devices and unnecessary breast stimulation. Silicone collectors that create a vacuum or suction may remove milk as well as collect it. In-bra milk-collection cups, breast shells and silver nippleettes may also involve sustained contact or pressure against the breast or nipple. Consider whether these products are needed and whether they may be contributing to repeated stimulation or milk removal. The effect will depend on the device and how it is used; evidence that each specific product causes oversupply is limited. La Leche League GB specifically cautions that silicone pumps used to collect leaking milk may unintentionally stimulate production (La Leche League GB, 2026). Review expressing patterns. Regular expression beyond what is needed for comfort, separation or an agreed feeding plan may maintain higher production for some breastfeeding parents. Expression may nevertheless be essential or preferred in many circumstances, so the aim is to review the individual plan rather than discourage expression generally (Johnson et al., 2020). Avoid reducing milk removal abruptly. Large changes to feeding frequency or deliberately leaving the breasts uncomfortably full can cause problems, including plugged ducts, mastitis or a reduction in supply below the baby’s needs. Changes to milk removal should be proportionate and guided by the individual circumstances (Johnson et al., 2020; La Leche League GB, 2026). Block feeding requires specialist support Block feeding is a technique sometimes used to reduce milk production in cases of confirmed hyperlactation. It involves feeding from one breast for a defined period before switching to the other, allowing milk to remain in the unused breast for longer and signalling a reduction in production. It is not a first-line response to every forceful let-down, and it should not be started simply because a baby coughs, splutters or pulls away during feeding. Mohrbacher (2013) cautions against using block feeding without considering the individual circumstances. Johnson et al. (2020) recommend that block feeding for idiopathic hyperlactation be undertaken with close supervision by a clinician experienced in breastfeeding medicine. Restricting milk removal can cause painful fullness, plugged ducts, mastitis or an excessive fall in milk production. Any plan needs to take account of the baby’s growth and milk intake, the breastfeeding parent’s breast health and the degree of oversupply. If the unused breast becomes uncomfortably full, a clinician may advise expressing a small amount for comfort rather than following a rigid schedule regardless of symptoms (Johnson et al., 2020; Mohrbacher, 2013). Block feeding is a specialist management technique, not a general strategy for slowing every forceful let-down. If oversupply is suspected, it is important to seek skilled support before attempting it. How milk production changes over time Milk production is regulated by interacting hormonal and local mechanisms. In the early stages of lactation, endocrine influences are particularly important as milk production becomes established following birth. As lactation progresses, local, autocrine regulation within the breast becomes increasingly influential, with milk removal and local feedback contributing to the regulation of production. These processes overlap rather than switching from one system to another at a precise point (Johnson et al., 2020). The age of the infant and the stage of lactation can therefore help inform assessment. A forceful flow in the early weeks may have different contributing factors from persistent oversupply later in lactation. The history should include how feeding was established, the baby’s milk transfer, the amount and frequency of any expression, and whether production has changed over time. It is also worth reviewing medicines and supplements. Some medicines can increase prolactin or otherwise affect milk production, and medicines or herbal products taken with the intention of increasing supply may contribute to oversupply in some circumstances. A clinician may need to review the full medication and supplement history, including any recent changes. Medication should not be stopped or altered without advice from the prescribing clinician or pharmacist (Johnson et al., 2020; La Leche League GB, 2026). If these management approaches do not help, or if oversupply is suspected, contact an International Board Certified Lactation Consultant (IBCLC) or another suitably experienced infant feeding professional. Further assessment can help identify the likely cause and establish an individualised management plan rather than continuing to try techniques without knowing what is driving the difficulty. Supporting bottle feeding when flow feels too fast During bottle feeding, the speed at which milk is delivered depends partly on the teat and partly on how the feed is offered. Teat labels such as ‘slow’, ‘medium’ or ‘fast’ are not necessarily comparable between manufacturers, and measured flow rates can vary between products (Pados et al., 2015; Pados, 2021). A baby who appears overwhelmed by bottle flow may benefit from reviewing the teat being used, the baby’s position and the pace of feeding. Responsive bottle feeding allows the baby opportunities to pause, regulate their intake and communicate when they need a break. NHS guidance recommends holding the baby in a supported, semi-upright position and keeping the bottle horizontal, with only a slight tilt, to help regulate milk flow and avoid milk flowing too quickly (NHS, 2024). Useful approaches include: Offer the teat gently and allow the baby to draw it into their mouth rather than pushing it in. Keep the bottle nearly horizontal, adjusting the angle as needed to regulate flow. Watch for signs that the baby needs a pause, such as turning away, slowing or stopping sucking, spilling milk or appearing uncomfortable. When a pause is needed, lower the bottle or remove the teat gently to stop the flow. Allow the baby to resume when ready. Avoid encouraging the baby to finish a bottle when they are showing signs of fullness or needing a break. Paced feeding is not about imposing a rigid rhythm or interrupting every few sucks. The baby’s own cues should guide the pace, with additional pauses if they are not managing the flow comfortably. Persistent coughing, choking, breathing changes or difficulty coordinating feeding warrant assessment rather than repeated experimentation with teats alone (NHS, 2024; Pados, 2021). See How to pace bottle feeds: a calm, practical guide, Choosing bottles and teats and Recognising infant swallowing during feeds for further information. Supporting the feeding relationship and knowing when to seek help Concerns about fast flow can leave families bracing for every feed. Families may already have tried multiple positions, teats or feeding strategies before seeking help. Repeating generic advice without assessing what is happening can leave them feeling that they are doing something wrong. A supportive approach recognises the feeding dyad as a whole. The baby’s behaviour, the breastfeeding parent’s comfort, the mechanics of milk delivery and the family’s circumstances all contribute to the feeding experience. There is no single ideal pattern of milk flow: some babies manage a brisk milk ejection comfortably, while others benefit from adjustments or further assessment. Arrange timely support if feeding is persistently painful, the baby is repeatedly distressed during feeds, there are concerns about wet nappies or weight gain, breast symptoms recur, or the baby regularly struggles to coordinate feeding. A midwife, health visitor, GP, infant feeding specialist or IBCLC can help assess the pattern and agree a plan that fits the family. Seek urgent medical advice if a baby has episodes of colour change, pauses in breathing, persistent breathing difficulty, unusual sleepiness, signs of dehydration, a fever in early infancy or is unable to feed. Green or bloody vomit, projectile vomiting, persistent vomiting or other signs of serious illness also require appropriate medical assessment (NHS, 2025). The most useful next step is not always to make milk flow slower, but to understand the feeding experience well enough that both parent and baby can feed as comfortably and safely as possible. References Johnson, H.M., Eglash, A., Mitchell, K.B., Leeper, K., Smillie, C.M., Moore-Ostby, L., Manson, N. and Simon, L. (2020) ‘ABM Clinical Protocol #32: Management of Hyperlactation’, Breastfeeding Medicine, 15(3), pp. 129–134. doi: 10.1089/bfm.2019.29141.hmj. La Leche League GB (2026) ‘Oversupply: too much milk’. Updated June 2026. Available at: https://laleche.org.uk/too-much-milk-and-oversupply/. Mohrbacher, N. (2013) ‘Block Feeding Dos & Don’ts’, 9 October. Available at: https://nancymohrbacher.com/blogs/news/tagged/block-feeding. NHS (2024) ‘Bottle feeding advice’. Last reviewed 2 April 2024. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/advice/. NHS (2025) ‘Reflux in babies’. Last reviewed 10 June 2025. Available at: https://www.nhs.uk/conditions/reflux-in-babies/. O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. doi: 10.1002/14651858.CD011065.pub2. Pados, B.F., Park, J., Thoyre, S.M., Estrem, H. and Nix, W.B. (2015) ‘Milk flow rates from bottle nipples used for feeding infants who are hospitalized’, American Journal of Speech-Language Pathology, 24(4), pp. 671–679. doi: 10.1044/2015_AJSLP-15-0011. Pados, B.F. (2021) ‘Milk flow rates from bottle nipples: what we know and why it matters’, Nursing for Women’s Health, 25(3), pp. 229–235. doi: 10.1016/j.nwh.2021.03.006. Pearson-Glaze, P. (2025a) ‘What is a fast let-down?’, Breastfeeding Support. Last revised 13 August 2025. Available at: https://breastfeeding.support/what-is-a-fast-let-down/. Pearson-Glaze, P. (2025b) ‘Oversupply of breast milk’, Breastfeeding Support. Last revised 10 November 2025. Available at: https://breastfeeding.support/oversupply-breast-milk/.

Research into infant tongue-tie continues to explore the relationship between oral anatomy and function, how feeding difficulties should be assessed, which infants may benefit from frenulotomy and what constitutes appropriate postoperative care. Some studies report improvements following frenulotomy, particularly in maternal nipple pain, while systematic reviews highlight limitations in the quality and consistency of the available evidence. For families exploring tongue-tie, interpreting research can be challenging. A study may examine one assessment method, one aspect of feeding or a specific postoperative intervention, whereas an individual feeding experience involves several interacting factors. This article reviews significant research themes, relevant professional guidance and areas where further evidence is needed. It distinguishes findings from individual studies, professional recommendations and practitioner audit data, as these sources answer different questions. 1. Anatomy and function need to be considered together Tongue-tie, also known as ankyloglossia, describes a lingual frenulum that restricts tongue movement. However, the presence or appearance of a lingual frenulum does not, by itself, establish whether it is functionally restrictive. Thomas et al. (2024), in a clinical report from the American Academy of Pediatrics (AAP), emphasised that anatomical variations do not necessarily cause breastfeeding difficulties. The report describes symptomatic ankyloglossia in relation to a restrictive frenulum and feeding difficulties that have not improved with appropriate lactation support. This distinction matters because feeding involves more than oral anatomy. Infant tongue movement and coordination, milk transfer, positioning, the feeding person's comfort and milk supply where relevant may all contribute to the feeding experience. A visible frenulum may be present without significant functional difficulty, while another infant may experience restricted tongue movement that contributes to feeding problems. The appearance of the frenulum alone cannot explain the whole feeding picture. Anatomy provides information; function provides context. Considering both alongside the experience of the feeding dyad helps distinguish an anatomical finding from a clinically significant functional difficulty. 2. Assessment tools are under scrutiny, but no single tool provides a diagnosis Several assessment tools have been developed to describe the appearance of the lingual frenulum and the function of the infant's tongue. These include the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), the Bristol Tongue Assessment Tool (BTAT), its pictorial version TABBY, and the Lingual Frenulum Protocol for Infants (LFPI). Necus et al. (2025) conducted a systematic review of assessment of tongue structure and function in infants. The review identified variation in the features assessed and in the evidence supporting the reliability and validity of different tools. The authors highlighted limitations in the evidence base and the need for more consistent assessment and reporting. The LFPI assesses structural and functional features together, which makes it relevant to discussions about comprehensive assessment. However, the available evidence does not establish that one tool produces better clinical outcomes than all alternatives. A tool's comprehensiveness should not be confused with proof of superior diagnostic accuracy or improved feeding outcomes. The AAP report also notes the lack of universally accepted diagnostic criteria for ankyloglossia (Thomas et al., 2024). Assessment tools can help organise observations and support consistency, but a score should not independently determine whether frenulotomy is indicated. Diagnosis and decisions about surgical release require a comprehensive assessment by the practitioner providing the procedure. This should include examination of tongue motility, observation of feeding, relevant history-taking and consideration of the feeding dyad. This matters because a tool may identify anatomical or functional features without establishing that those features are responsible for the feeding difficulties described. Equally, a score should not replace clinical judgement or consideration of other possible explanations. Further research is needed to establish how consistently different assessment tools are used, how well they perform in different settings and whether their use improves outcomes for infants and families. 3. Bottle-feeding deserves greater attention in tongue-tie research Much of the public discussion and research surrounding tongue-tie has focused on breastfeeding. However, feeding difficulties are not limited to breastfeeding, and families may seek assessment because of concerns about bottle-feeding. The NHS provides information specifically addressing tongue-tie and bottle-feeding. It describes difficulties that may include prolonged feeds, milk loss from the mouth, difficulty maintaining feeding and concerns about weight gain. These experiences warrant consideration, but none is specific to tongue-tie and each can have other explanations (NHS, 2023). Chinnadurai et al. (2015) reviewed evidence about treatment of ankyloglossia for reasons other than breastfeeding. Their systematic review found that the evidence for several non-breastfeeding outcomes was limited, illustrating the wider problem of drawing firm conclusions from small or methodologically weak studies. The Association of Tongue-tie Practitioners (ATP) has also published a bottle-feeding audit. Audit findings can contribute useful information about clinical experiences and reported outcomes, but an audit is not equivalent to a controlled study. Its interpretation depends on how information was collected, which cases were included and how outcomes were measured. Research specifically designed around bottle-feeding is needed. This includes consistent definitions of feeding difficulties, validated outcome measures and follow-up that considers whether any changes are meaningful to the infant and family. 4. Frenulotomy outcomes remain an important area of uncertainty Frenulotomy is a procedure in which the lingual frenulum is divided to reduce restriction. Research has investigated outcomes including maternal nipple pain, breastfeeding self-efficacy, infant feeding, milk transfer and weight gain. Some studies report improvements following the procedure, particularly in maternal nipple pain. However, study design and outcome measurement vary, and not all reported improvements can be confidently attributed to the procedure itself. Silva et al. (2026) published an umbrella review of systematic reviews examining lingual frenotomy in infants up to one year of age. Fifteen systematic reviews were included. Using the AMSTAR 2 assessment, the authors classified 14 reviews as having critically low confidence and one as having moderate confidence. The authors concluded that the underlying reviews had substantial methodological limitations. Their findings highlight the difficulty of drawing firm conclusions about the benefits of frenotomy across breastfeeding-related outcomes. These findings do not establish that no infant benefits from frenulotomy. They indicate that the strength of evidence differs between outcomes and that current research cannot provide a simple answer for every feeding difficulty. It is also important to distinguish between a change reported after a procedure and a change demonstrated to result from that procedure. Feeding may change over time for several reasons, including infant maturation, feeding support, changes in positioning and the natural course of the original difficulty. 5. Long-term outcomes are not established Families sometimes encounter claims that tongue-tie division may prevent later speech difficulties, sleep-disordered breathing or other problems. These are important questions, but the evidence needs to support the specific outcome being claimed. Thomas et al. (2024) concluded that frenotomy to prevent future speech articulation difficulties or obstructive sleep apnoea is not evidence-based. This does not mean that every possible relationship between tongue function and later development has been fully investigated. It means that preventive benefits from infant frenulotomy have not been established. Speech development involves multiple factors, and a restriction observed in infancy does not necessarily predict a later speech disorder. Similarly, an association between oral anatomy and sleep-related symptoms would not, on its own, demonstrate that releasing a frenulum in infancy prevents those symptoms. Research with longer follow-up, appropriate comparison groups and clearly defined outcomes would be needed to establish whether early frenulotomy changes these longer-term outcomes. For families, a proposed future benefit should therefore be distinguished from a current, identifiable functional difficulty. 6. Objective measures of feeding are being explored Feeding assessment often includes observation of the infant and the feeding person's experience. Researchers are also exploring whether objective measurements can provide additional information about feeding mechanics and changes following frenulotomy. Siggaard, Rytter and Lildholdt (2026) investigated an electronic baby bottle designed to record intraoral forces during sucking. Their prospective study included 106 infants under three months of age, assessed at baseline and one week later. Eighty-five infants underwent frenotomy, while 21 infants who did not meet the study's diagnostic criteria formed a comparison group. The electronic bottle received favourable subjective ratings from clinicians, but the study did not identify a significant change in the device's signal following frenotomy. The authors concluded that subjective interpretation of its readings was insufficient as a standalone diagnostic approach and that further validation was needed. This study illustrates the difference between developing a measurement method and establishing its clinical value. An objective measurement may help researchers describe sucking patterns, but it must be shown to measure something meaningful and reliably distinguish relevant clinical differences. A change in a feeding parameter also needs to be interpreted alongside the infant's feeding experience, growth and coordination, as well as the family's experience of feeding. Future research could combine objective feeding measurements with validated clinical assessments and family-reported outcomes. This would help establish whether measured changes correspond to improvements that matter in everyday feeding. 7. A multidisciplinary approach recognises the complexity of feeding Infant feeding is not explained by oral anatomy alone. It involves the infant's oral movement and coordination, the feeding person's comfort and milk supply where relevant, feeding technique and the wider circumstances of the feeding dyad. A multidisciplinary approach can bring different perspectives to the same feeding experience. A practitioner providing surgical release is responsible for assessing whether a restrictive frenulum is present, whether the findings are consistent with the reported difficulties and whether a procedure is appropriate. The assessment includes consideration of relevant history, tongue movement and observed feeding. An International Board Certified Lactation Consultant (IBCLC) can provide specialist assessment and support around breastfeeding and lactation. This may include attachment, positioning, milk transfer, milk supply, nipple pain and the feeding person's experience. Lactation support may also help identify factors that could contribute to feeding difficulties independently of tongue-tie. Other infant-feeding specialists may contribute according to their training and scope of practice. Bodywork practitioners may work with aspects of muscular tension or movement, depending on their approach, qualifications and the individual circumstances. However, the evidence varies between bodywork approaches, and findings about one method should not automatically be applied to another. Thomas et al. (2024) emphasised the importance of a team approach and collaboration with lactation professionals when assessing breastfeeding difficulties. The value of multidisciplinary care lies in recognising that different practitioners may contribute different forms of expertise, rather than assuming that one intervention addresses every contributing factor. This does not mean that every family requires every type of support. The appropriate involvement depends on the infant's needs, the feeding difficulties and the findings of assessment. 8. Pain management is part of the procedure and aftercare discussion Pain associated with frenulotomy and the period following the procedure is an important consideration for families. Practices vary, and the evidence supporting different approaches to pain management is not equally strong. The infant's age, the procedure performed, the clinical setting and the method used to assess pain can affect the available evidence. Studies may also measure pain in different ways, making direct comparisons difficult. It is important to distinguish between discomfort associated with the procedure itself and feeding changes or distress that may occur afterwards. These experiences may have several possible explanations and should not automatically be attributed to a single cause. Thomas et al. (2024) emphasised discussing pain control, procedural risks, alternatives and postoperative care as part of informed consent. Clear information can help families understand what to expect and when further assessment may be needed. Further research using consistent pain measures and appropriate comparison groups would help clarify the effectiveness of different approaches. 9. Bleeding risk, complications and emergency care Bleeding is a recognised complication of frenulotomy, and procedural safety is an important part of informed consent. The ATP publishes audit data on complications following tongue-tie division, alongside separate guidance on the management of prolonged bleeding. The ATP's Report on the ATP audit of divisions performed in 2025 received 46 responses and covered 8,061 procedures. The report recorded the following findings: Five ambulance calls, equivalent to approximately 0.06% of the 8,061 procedures. Each respondent who reported calling an ambulance had done so once. One baby was reported as having been transferred in. Four babies required medical intervention for bleeding, including topical medication such as adrenaline or tranexamic acid, cautery or suturing. No confirmed infections related to division were reported. Five recurrences were reported as having been redivided elsewhere. One baby developed cysts. One respondent reported that three babies were not achieving full feeds one week after division. These findings provide a recent UK practitioner-audit perspective on reported complications. However, the audit reflects the responses received rather than necessarily capturing every procedure performed in the UK. The 46 responses should not be interpreted as 46 individual practitioners unless the report confirms that each response came from a different practitioner. The findings also depend on the information submitted by respondents. The five ambulance calls and four cases requiring medical intervention for bleeding are different outcomes and should not be combined. The figure of approximately 0.06% is a calculation from the number of reported ambulance calls divided by the number of procedures covered by the audit. It should not be interpreted as a definitive risk estimate for every infant undergoing frenulotomy. The ATP's bleeding-management guidance should be considered separately from the annual audit. The guidance includes a management flow chart updated in 2025. It provides information for managing prolonged bleeding, but it should not be confused with a controlled trial comparing treatment approaches. Vitamin K status is also relevant to procedural safety. Vitamin K helps blood clot normally, and vitamin K deficiency bleeding can be serious. The infant's vitamin K history therefore forms part of the wider safety considerations around a procedure. Audit data, professional guidance and individual clinical assessment each contribute different information. Together, they help describe complications reported in practice while highlighting the importance of accurate records, clear escalation pathways and continued review of safety data. 10. Postoperative exercises and wound management remain debated Aftercare following frenulotomy is an area of continuing discussion. Approaches vary, particularly around whether the wound should be manipulated or stretched, how frequently exercises are advised and what outcomes are expected. Smart, Grant and Tseng (2025) published a scoping review of preoperative and postoperative care following surgery for ankyloglossia. The authors identified substantial variation in the care protocols studied and concluded that the evidence base was limited by inconsistent approaches and study methods. Miller et al. (2025) investigated stretching exercises after infant frenotomy in a prospective interventional study involving 88 infants. There were 63 infants in the stretching group and 25 in the non-stretching group. Of those assigned to stretching, 36 were adherent to the exercises and 27 were not. The authors reported differences in recurrent ankyloglossia, persistent feeding difficulties and revision procedures between the groups, with outcomes differing according to adherence. These findings contribute to the debate, but the study was conducted at a single centre and its group allocation and adherence patterns need to be considered when interpreting the results. The findings do not establish that every infant requires the same regimen. Valle-Del Barrio et al. (2025) studied 212 neonates following frenotomy. All families were advised to undertake postoperative exercises, and infants were reassessed after the procedure. The authors reported that 30 infants underwent a second frenotomy. Because all families were advised to undertake exercises and there was no group that did not receive them, the study cannot independently establish whether exercises prevented readhesion. The ATP's position statement on disruptive wound management also discusses uncertainty around postoperative wound manipulation. It notes that published evidence has not established which approach achieves optimal healing or reliably prevents the need for redivision. It is important to distinguish between exercises intended to support oral movement and practices that repeatedly disturb the healing wound. These are not necessarily the same intervention, and research findings about one approach should not automatically be applied to another. The current evidence does not establish a single universally appropriate postoperative regimen. Further robust studies are needed to compare clearly defined approaches, measure adherence, monitor adverse effects and follow infants long enough to assess meaningful outcomes. 11. Readhesion and healing need careful interpretation Scar formation, readhesion and recurrent functional restriction are related topics, but they are not interchangeable. Healing tissue can change in appearance and texture, while readhesion describes the return of a connection or restriction following division. An anatomical finding does not automatically establish that feeding function has deteriorated. Valle-Del Barrio et al. (2025) reported readhesion-related outcomes following neonatal frenotomy, including the number of infants who underwent a second procedure. Their study contributes information about what happened in one clinical cohort, but its observational design and lack of a comparison group not receiving exercises limit the conclusions that can be drawn about prevention. Miller et al. (2025) also examined recurrent ankyloglossia and revision procedures in relation to postoperative stretching. Their findings add to the evidence under discussion, but the study's design and adherence patterns mean that the results should not be treated as a definitive answer for all infants or all aftercare approaches. More research is needed to define clinically meaningful readhesion, distinguish anatomical findings from recurrent functional difficulties and establish which interventions, if any, improve outcomes without causing unnecessary pain or distress. 12. Hypermobility and connective-tissue conditions are being explored The relationship between connective-tissue conditions and oral anatomy is another area of interest. Families may encounter information linking tongue-tie with hypermobility or conditions such as Ehlers-Danlos syndrome (EDS). Savasta et al. (2021) reported a retrospective study comparing 40 children with EDS with 170 controls. The authors found a higher prevalence of absent or hypoplastic lingual frenulum in the EDS group. The study raises questions about the relationship between connective-tissue characteristics and the development or appearance of the lingual frenulum. However, it does not establish how these anatomical findings relate to feeding function or whether frenulotomy would benefit an individual child. The absence of a visible or typical frenulum does not necessarily establish that tongue movement is unrestricted, just as a visible frenulum does not automatically demonstrate functional restriction. The clinical significance of anatomical findings needs to be assessed rather than assumed. The study was retrospective and relatively small. Further research is needed before drawing broader conclusions about feeding outcomes, assessment or treatment in children with connective-tissue conditions. 13. Lip-tie and buccal-tie release remain controversial Families may encounter claims that the upper labial frenulum, commonly called the lip-tie, or the buccal frenula contribute to breastfeeding or bottle-feeding difficulties. These claims need to be considered in the context of the available evidence. The presence of a visible upper labial frenulum is common and does not, on its own, establish a feeding problem. Nakhash et al. (2019) reviewed the literature on upper lip-tie and breastfeeding. They found no randomised controlled trials and concluded that the evidence supporting routine release in infants with breastfeeding difficulties was poor. They also noted that the commonly used Kotlow classification had not been shown to reliably predict breastfeeding difficulty. The American Academy of Otolaryngology–Head and Neck Surgery clinical consensus statement on ankyloglossia in children discusses the lack of evidence for buccal frenulum release and reached consensus against releasing buccal frenula to improve breastfeeding (Messner et al., 2020). The ATP's 2026 position statement on lip-tie and buccal-tie similarly notes that published evidence does not establish a link between these structures and breastfeeding or bottle-feeding difficulties, and that evidence supporting buccal frenulum release for these concerns is lacking. It is important to distinguish normal oral anatomy from evidence that a structure is causing a functional difficulty. Claims that a release will improve feeding need to be supported by evidence specific to that procedure and outcome. 14. Preventive frenulotomy is not supported by established evidence Another question is whether frenulotomy should be performed in infancy to prevent possible difficulties later in life, even when a current functional problem has not been established. This is different from considering a procedure where an infant has a restrictive frenulum and an assessment identifies associated functional difficulties. Preventive treatment requires evidence that the intervention reduces the likelihood of a future problem and that the expected benefit outweighs the risks and burdens of treatment. Thomas et al. (2024) concluded that frenotomy to prevent future speech articulation difficulties or obstructive sleep apnoea is not evidence-based. The absence of strong evidence for these proposed preventive benefits means that they should not be presented to families as established outcomes. Research into longer-term outcomes remains important, but uncertainty about future risk is not the same as evidence that a procedure will prevent it. Decisions about treatment are best understood in relation to current function, assessment findings and the evidence for the specific outcome being considered. 15. Professional guidance, audits and research each contribute different evidence Research papers are only one part of the information available to families and practitioners. Professional position statements, clinical guidance and audit reports can also contribute to understanding current practice and the questions that remain unresolved. These sources serve different purposes. A systematic review evaluates findings across studies, although its conclusions depend on the quality of the underlying research. A clinical report or guideline sets out recommendations based on available evidence and professional judgement. A position statement explains an organisation's view on a particular issue. An audit describes information collected about practice or outcomes, but it may not establish cause and effect. The ATP's annual complications audits are valuable because they provide recurring information about complications reported by participating practitioners. The 2025 audit, covering 8,061 procedures across 46 responses, adds recent data to the discussion of procedural safety. However, the findings should be interpreted with the audit's response numbers and reporting methods in mind. Similarly, the ATP's bleeding guidance and position statement on disruptive wound management provide information about current professional approaches, but they should not be confused with controlled trials demonstrating the superiority of one intervention. No single source answers every question about tongue-tie. Understanding the evidence requires attention to study design, sample size, follow-up, the outcomes measured and whether the findings are relevant to the particular infant and feeding difficulty being considered. 16. What the evidence means for families Research into tongue-tie is continuing to develop. Some findings support the possibility of benefit from frenulotomy for particular feeding-related outcomes, while other proposed benefits remain uncertain or unsupported by sufficiently robust evidence. Several themes are consistent across the literature: The appearance of the lingual frenulum alone cannot establish whether it is functionally restrictive. Assessment tools can support the assessment process, but a score is not a diagnosis. Feeding difficulties need to be understood in the context of the infant and feeding dyad. Evidence relating to breastfeeding is more developed than evidence for bottle-feeding, and important gaps remain. Improvements reported after frenulotomy should be interpreted in the context of study design and other factors that may influence feeding. Evidence for long-term preventive benefits remains limited. Postoperative exercises and wound management remain areas of debate, with uncertainty about which approaches produce the best outcomes. Annual audits contribute useful information about reported complications, but they are not substitutes for well-designed studies with consistent outcome measures and follow-up. For families, the aim is not to find one paper that provides a definitive answer for every infant. It is to understand what the evidence can and cannot tell us, how it relates to the feeding difficulties being experienced and what other factors may be relevant. A balanced discussion recognises both the potential for benefit and the limitations of current knowledge. It also recognises that feeding is a relationship between an infant and their caregiver, and that the most useful assessment considers function, experience and context alongside anatomy. References Association of Tongue-tie Practitioners (ATP) (2022) Position statement: Disruptive wound management. Available at: https://www.tongue-tie.org.uk/position-statements (Accessed: 24 October 2026). Association of Tongue-tie Practitioners (ATP) (2025a) Report on the ATP audit of divisions performed in 2025. Available at: https://irp.cdn-website.com/f3c762d5/files/uploaded/Report+on+the+ATP+audit+of+divisions+performed+in+2025.pdf (Accessed: 24 October 2026). Association of Tongue-tie Practitioners (ATP) (2025b) Management of prolonged bleeding post tongue-tie division: flow chart 2025. Available at: https://www.tongue-tie.org.uk/bleeding-guidelines (Accessed: 24 October 2026). Association of Tongue-tie Practitioners (ATP) (2026) Position statement: Lip-tie and buccal-tie. Available at: https://www.tongue-tie.org.uk/position-statements (Accessed: 24 October 2026). Chinnadurai, S., Francis, D.O., Epstein, R.A., Morad, A., Kohanim, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review’, Pediatrics, 135(6), pp. e1467–e1474. Available at: https://doi.org/10.1542/peds.2015-0660. Messner, A.H. et al. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. Available at: https://doi.org/10.1177/0194599820915457. Miller, J.E., Chung, H.R., Marshall, C.R., Wilhalme, H.M. and West, A.N. (2025) ‘Outcomes of stretching exercises after lingual frenotomy in infants: a prospective, interventional study’, International Journal of Pediatric Otorhinolaryngology, 191, article 112280. Available at: https://doi.org/10.1016/j.ijporl.2025.112280. Mills, N. et al. (2020) ‘Imaging the breastfeeding swallow: pilot study utilizing real-time MRI’, Laryngoscope Investigative Otolaryngology, 5(3), pp. 572–579. Available at: https://doi.org/10.1002/lio2.397. Nakhash, R., Wasserteil, N., Mimouni, F.B., Kasirer, Y.M., Hammerman, C. and Bin-Nun, A. (2019) ‘Upper lip tie and breastfeeding: a systematic review’, Breastfeeding Medicine, 14(2), pp. 83–87. Available at: https://doi.org/10.1089/bfm.2018.0174. National Health Service (NHS) (2023) Tongue-tie and bottle feeding. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-challenges/tongue-tie-and-bottle-feeding/ (Accessed: 24 October 2026). Necus, E., Claessen, M., Hennessey, N. and Smart, S. (2025) ‘Assessment of tongue structure and function in infants for the diagnosis of ankyloglossia: a systematic review’, International Journal of Pediatric Otorhinolaryngology, 196, article 112485. Available at: https://doi.org/10.1016/j.ijporl.2025.112485. Savasta, S. et al. (2021) ‘Absence of lingual frenulum in children with Ehlers-Danlos syndrome: a retrospective study of forty cases and literature review of a twenty years long debate’, Minerva Pediatrica, 73(3), pp. 230–235. Available at: https://doi.org/10.23736/S2724-5276.19.05530-0. Siggaard, L.D., Rytter, D. and Lildholdt, T. (2026) ‘Using the electronic baby bottle to support tongue-tie diagnosis in infants: a prospective study’, Acta Oto-Laryngologica. Available at: https://doi.org/10.1080/00016489.2026.2688878. Silva, B.V. da, Barollo, A.V., Sá, N. da N.L., Oliveira, L.B. and Sanglard, L.F. (2026) ‘Lingual frenotomy in breastfeeding infants: an umbrella review’, International Journal of Paediatric Dentistry, 36(1), pp. 90–104. Available at: https://doi.org/10.1111/ipd.70031. Smart, S., Grant, H. and Tseng, R.J. (2025) ‘Beyond surgery: pre- and post-operative care in children with ankyloglossia’, International Journal of Paediatric Dentistry, 35(2), pp. 318–338. Available at: https://doi.org/10.1111/ipd.13235. Thomas, J. et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 154(2), article e2024067605. Available at: https://doi.org/10.1542/peds.2024-067605. Valle-Del Barrio, B., Maya-Enero, S., Prat-Ortells, J., López-Vílchez, M.Á. and Candel-Pau, J. (2025) ‘Readhesion of tongue-tie following neonatal frenotomy: incidence and impact of postoperative exercises in a prospective observational study’, Children, 12(8), article 971. Available at: https://doi.org/10.3390/children12080971.

If tongue-tie runs in your family, you may also have heard about joint hypermobility, connective tissue conditions or Ehlers–Danlos syndromes (EDS). Some families and healthcare professionals have questions about whether these features could be connected, particularly when an infant has feeding difficulties, a restrictive lingual frenulum or concerns about healing after a tongue-tie division. There are some interesting findings in the research, but the relationship is not straightforward. Studies have explored the presence or absence of oral frenula in people with EDS, and separate research suggests that tongue-tie can occur in families. However, these findings do not establish that hypermobility causes tongue-tie or that it affects healing after frenulotomy. Understanding what is known, what remains uncertain and what the research has not yet answered can help families make sense of these discussions. Understanding joint hypermobility and connective tissue Joint hypermobility means that one or more joints can move beyond the range usually expected. Some people are naturally very flexible without experiencing problems. In others, hypermobility occurs alongside pain, instability or other symptoms and may be associated with a hypermobility spectrum disorder (HSD) or a connective tissue condition such as Ehlers–Danlos syndrome (Castori et al., 2017; Tofts et al., 2023). Ehlers–Danlos syndromes are a group of heritable connective tissue disorders. Connective tissue helps support and connect structures throughout the body, including skin, ligaments, blood vessels and other tissues. Depending on the EDS subtype, features may include unusually flexible joints, stretchy or fragile skin, easy bruising and differences in wound healing. The characteristics and underlying mechanisms vary between subtypes, so EDS is not one uniform condition (Malfait et al., 2017). Collagen is an important component of connective tissue, helping tissues maintain their structure and mechanical properties. However, connective tissue also contains other proteins and extracellular matrix components. It would therefore be too simplistic to assume that all hypermobility, tissue elasticity or wound-healing differences have one explanation or involve the same collagen type. It is also important to distinguish joint hypermobility from a diagnosed connective tissue disorder. Being flexible, or having a family member who is flexible, does not automatically mean that someone has EDS or HSD (Castori et al., 2017; Tofts et al., 2023). The lingual frenulum and Ehlers–Danlos syndromes The lingual frenulum is the fold of tissue connecting the underside of the tongue with the floor of the mouth. It varies in appearance between individuals. Tongue-tie, also called ankyloglossia, describes a congenital variation in which the lingual frenulum restricts tongue movement. The presence of a visible frenulum alone does not establish whether a restriction is present or whether it affects feeding (Messner et al., 2020). Research into EDS has explored an interesting finding: some studies have reported that the lingual frenulum, the lower labial frenulum or both may be absent or underdeveloped in people with particular EDS subtypes. De Felice et al. (2001) reported an association between absent oral frenula and classical or hypermobility-type EDS in a small group of patients. However, later studies did not consistently reproduce the findings. Shankar et al. (2006), for example, concluded that the absence of the lower labial or lingual frenulum was not a useful clinical marker for EDS in their UK population. Machet et al. (2010) found that the absence of these structures could be a specific finding in their study population, but it was not present in everyone with EDS. A later study of children with EDS again reported an association, illustrating why this topic continues to be discussed (Savasta et al., 2019). These studies concern the presence, absence or development of the frenulum. They do not establish that a frenulum which is present is necessarily more elastic, nor do they show that increased tissue elasticity causes a restrictive tongue-tie. This distinction matters because three different observations should not be treated as equivalent: An absent frenulum: the structure cannot be identified, or appears to be absent, on examination. A present but unusually elastic frenulum: this is a possible feature that would need to be investigated directly; it cannot be assumed from the studies reporting absent frenula. A restrictive frenulum: the frenulum limits tongue movement. Its functional significance depends on the individual and cannot be determined by appearance alone. The existing EDS research does not demonstrate that a baby with hypermobility has a frenulum that is present but so elastic that it causes, or disguises, tongue-tie. Nor does it establish that an absent frenulum means tongue movement must be unrestricted in every respect. This is an important gap in the evidence. The relationship between connective tissue properties, the development of the lingual frenulum and tongue function needs further study before a specific explanation can be established. For more on the relationship between anatomy and feeding, see Tongue-tie assessment tools: appearance, function and validation and A guide to understanding your baby’s oral function. Pseudo-tie and hypermobility The term pseudo-tie is sometimes used when a tongue appears restricted or its movement is limited, but the limitation may not be explained by a restrictive lingual frenulum alone. It is not a single, clearly defined diagnosis, and its use does not establish what is causing the observed movement pattern. Tongue movement involves the interaction of oral structures, muscles, nerves and coordination. Feeding also depends on how these systems work together with the infant’s development, state and feeding task. Consequently, a baby may have feeding difficulties or limited-looking tongue movement for reasons other than a restrictive frenulum, and more than one factor may be present (Messner et al., 2020). Could differences in connective tissue properties influence the way the frenulum moves or feels? This is a reasonable question for research, particularly given the published observations about absent or underdeveloped frenula in some people with EDS. However, there is not currently sufficient evidence to conclude that hypermobility causes pseudo-tie, that unusually elastic tissue explains restricted tongue movement, or that either feature can be identified reliably from an infant’s family history. A term such as pseudo-tie should therefore not be taken as proof that a frenulum is normal, that it is restrictive, or that hypermobility is responsible. The relevant question remains what the assessment shows about the infant’s tongue movement and feeding, alongside any other factors that may be contributing. Further reading is available in What does a tongue-tie assessment consider? and Infant oral anatomy: structure, function and feeding. Family history and infant assessment Family history is relevant to this topic for two separate reasons: tongue-tie itself may have a genetic component, and some forms of joint hypermobility and EDS have a hereditary basis. These are related areas of interest, but they are not evidence of one shared cause. Tongue-tie is present from birth, and familial patterns have been reported. Klockars and Pitkäranta (2009) discussed inheritance in families with ankyloglossia, while Han et al. (2012) examined family histories in a group of 149 patients who had undergone frenuloplasty. Their findings suggested a hereditary component in some cases, although the authors’ proposed inheritance pattern cannot be assumed to apply to every family. Other reports have described different possible inheritance patterns (Moore et al., 1987; Klockars and Pitkäranta, 2009; Han et al., 2012). The overall picture is that genetic factors may contribute to tongue-tie in some families, but its causes and inheritance are not fully understood. A family history does not mean that every child will have tongue-tie, and the absence of a known family history does not rule it out. EDS is also a group of heritable conditions, although the genetic basis varies by subtype. For hypermobile EDS, a single causative gene has not been established for routine diagnostic testing in the way that genes have been identified for several other EDS subtypes (Malfait et al., 2017). Assessing joint hypermobility in infants presents additional challenges because mobility and physical development change as children grow. The 2023 paediatric framework for joint hypermobility was designed for children from five years of age through biological maturity, rather than for diagnosing hypermobility in young infants (Tofts et al., 2023). A family history of tongue-tie may therefore be relevant when considering an infant’s oral anatomy, just as a family history of hypermobility or a diagnosed connective tissue condition may be relevant to their wider health history. Neither history, on its own, establishes a diagnosis or explains an individual infant’s feeding difficulties. My article on the causes of tongue-tie explores what is currently understood about its possible genetic and developmental influences. Wound healing in the hypermobile population After a frenulotomy, the small wound beneath the tongue goes through a normal healing process. Understanding this process helps distinguish expected changes in the wound from concerns about persistent restriction or recurrent symptoms. Normal healing after frenulotomy Following division of the lingual frenulum, a wound may be visible beneath the tongue. It can look red initially and then develop a white or yellow appearance as healing progresses. This change in colour is commonly part of normal oral wound healing and does not, by itself, mean that the wound is infected or that tongue-tie has returned. The wound usually becomes smaller and heals over approximately one to two weeks, although individual healing varies (Worcestershire Acute Hospitals NHS Trust, 2025). The mouth has a moist environment and a rich blood supply, which support tissue repair. As with other wounds, healing involves overlapping stages of inflammation, tissue repair and remodelling. The appearance of the wound changes during these stages, and the visible healing process should not be confused with the final functional outcome. When healing does not follow the expected course Sometimes, healing can involve more substantial scar tissue or the return of restriction. After frenulotomy, the frenulum may appear to have re-formed or the tongue may again have restricted movement. These observations are often discussed under the term reformation, although the underlying explanation can vary. Residual tissue, healing and scar formation may contribute, and a return of feeding difficulties does not by itself prove that the frenulum has regrown (Messner et al., 2020). It is important to distinguish normal wound healing from a problem with the outcome. A white or yellow wound, for example, is not sufficient evidence of abnormal healing. More relevant concerns include persistent or renewed restriction of tongue movement, ongoing feeding difficulties, or other symptoms that warrant reassessment. A wound that appears increasingly inflamed, is associated with fever, or accompanies a significant deterioration in feeding also needs appropriate clinical attention. Connective tissue conditions and scar formation Some people with EDS experience skin fragility, delayed wound healing or abnormal scar formation. These features vary between EDS subtypes and individuals, and the evidence on skin healing cannot automatically be applied to the oral mucosa or to a wound created by infant frenulotomy (Malfait et al., 2017; Angwin et al., 2024). Scar formation itself is a complex process involving inflammation, collagen deposition and tissue remodelling. Research into hypertrophic scars and other abnormal scars helps explain these mechanisms, but it does not establish how an infant’s lingual frenulum will heal after division (Aarabi et al., 2007). At present, there is not enough evidence to conclude that babies with joint hypermobility, a family history of EDS or a suspected connective tissue difference are more likely to develop restrictive scar tissue after frenulotomy. Nor is there sufficient evidence to predict an infant’s healing outcome from the apparent elasticity of their tissues. Corticosteroid injections and emerging approaches to scar tissue Corticosteroid injections are used in some settings to treat certain types of abnormal scar, including hypertrophic and keloid scars. Their use depends on the type, location and severity of the scar, and treatment can have adverse effects (British Association of Dermatologists, n.d.). The use of corticosteroids injected into scar tissue following infant frenulotomy is a different question. This is an emerging concept, not an established routine treatment for tongue-tie reformation in babies. Evidence about steroid injections for skin scars cannot be assumed to demonstrate safety or effectiveness when injected into the tissues beneath an infant’s tongue. A 2026 case report describing severe scarring after an unsuccessful infant frenulotomy specifically noted that intralesional corticosteroid treatment was not considered because of limited safety data and lack of regulatory approval for that use in infants with oral mucosal fibrosis (Salvage Frenuloplasty case report, 2026). A single case report cannot establish a standard of care, but it illustrates the uncertainty surrounding this approach. Further research is needed before conclusions can be drawn about whether connective tissue conditions affect healing after frenulotomy, which infants might be at greater risk of abnormal scarring, or whether steroid injections have a role in managing oral scar tissue in this population. Hypermobility and tongue-tie reformation The possible relationship between hypermobility and tongue-tie reformation brings together several areas where the evidence remains incomplete: the development of the frenulum, connective tissue properties, normal wound healing and scar formation. Research has described absent or underdeveloped oral frenula in some people with EDS. Other research has examined skin fragility and abnormal scarring in connective tissue conditions. However, these findings do not establish that a baby with hypermobility is more likely to experience reformation after frenulotomy. It is also not yet known whether the properties of the lingual frenulum in infants with connective tissue conditions differ in a way that affects healing, or whether any such differences would have a clinically meaningful effect on tongue movement or feeding. These questions cannot be answered by extrapolating from skin wounds or from studies of absent frenula in people with EDS. For families whose babies experience persistent or returning feeding difficulties after frenulotomy, the presence of a family history of hypermobility may be one part of the wider history. It is not, however, proof that connective tissue differences caused the outcome. The same applies to a family history of tongue-tie: familial patterns may exist, but they do not determine how an individual baby will heal. What the evidence means for families There are three separate questions that are sometimes grouped together in discussions about tongue-tie and hypermobility: Can tongue-tie run in families? Research suggests that tongue-tie may have a genetic component, although the precise causes and inheritance patterns remain uncertain. Can EDS be associated with differences in oral frenula? Some studies have reported absent or underdeveloped frenula in people with EDS, but findings are inconsistent. This is not the same as demonstrating that a present frenulum is unusually elastic or restrictive. Does hypermobility affect healing after frenulotomy? There is currently insufficient direct evidence to establish that it increases the risk of abnormal scar formation or reformation in infants. These questions are worth investigating because they may help improve understanding of oral anatomy, feeding and healing. However, they should not be treated as if research has already established a single explanation linking all three. Conclusion Tongue-tie may have a genetic component, and joint hypermobility and EDS are relevant to connective tissue research. Studies have also explored the absence or underdevelopment of oral frenula in people with EDS. What remains uncertain is whether connective tissue differences influence the elasticity or function of a frenulum that is present, or whether hypermobility has any effect on healing after infant frenulotomy. Normal wound healing, persistent restriction and reformation are not interchangeable, and the evidence about skin scarring cannot simply be transferred to the lingual frenulum. Corticosteroid injections into oral scar tissue are an emerging concept, with important unanswered questions about their use in infants. This remains an area for further research. As evidence develops, it may help clarify whether any meaningful relationship exists between hypermobility, tongue-tie and healing, and whether that knowledge should inform future clinical guidance. References Aarabi, S., Longaker, M.T. and Gurtner, G.C. (2007) ‘Hypertrophic scar formation following burns and trauma: new approaches to treatment’, PLoS Medicine, 4(9), e234. Available at: https://doi.org/10.1371/journal.pmed.0040234 Angwin, C. et al. (2024) ‘Skin fragility and wound management in Ehlers–Danlos syndromes: a report by the International Consortium on Ehlers–Danlos Syndromes and Hypermobility Spectrum Disorders Skin Working Group’, Clinical and Experimental Dermatology, 49(12), pp. 1496–1503. Available at: https://doi.org/10.1093/ced/llae201 British Association of Dermatologists (n.d.) Keloid scars. Available at: https://www.bad.org.uk/pils/keloid-scars/ Castori, M. et al. (2017) ‘A framework for the classification of joint hypermobility and related conditions’, American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), pp. 148–157. Available at: https://doi.org/10.1002/ajmg.c.31539 De Felice, C. et al. (2001) ‘Absence of the inferior labial and lingual frenula in Ehlers-Danlos syndrome’, The Lancet, 357(9267), pp. 1500–1502. Available at: https://doi.org/10.1016/S0140-6736(00)04661-4 Han, S.H. et al. (2012) ‘A study on the genetic inheritance of ankyloglossia based on family history’, Archives of Plastic Surgery, 39(4), pp. 329–332. Available at: https://doi.org/10.5999/aps.2012.39.4.329 Klockars, T. and Pitkäranta, A. (2009) ‘Inheritance of ankyloglossia (tongue-tie)’, Clinical Genetics, 75(1), pp. 98–99. Machet, L. et al. (2010) ‘Absence of inferior labial and lingual frenula in Ehlers-Danlos syndrome: a minor diagnostic criterion in French patients’, American Journal of Clinical Dermatology, 11(4), pp. 269–273. Available at: https://doi.org/10.2165/11530090-000000000-00000 Malfait, F. et al. (2017) ‘The 2017 international classification of the Ehlers-Danlos syndromes’, American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), pp. 8–26. Available at: https://doi.org/10.1002/ajmg.c.31552 Messner, A.H. et al. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. Available at: https://doi.org/10.1177/0194599820915457 Moore, G.E. et al. (1987) ‘Familial ankyloglossia (tongue-tie)’, Journal of Medical Genetics, 24(12), pp. 715–716. Savasta, S. et al. (2019) [Study on oral manifestations in children with Ehlers–Danlos syndrome]. [Bibliographic details to be confirmed before publication]. Shankar, S., Shirley, E. and Burrows, N.P. (2006) ‘Absence of inferior labial or lingual frenula is not a useful clinical marker for Ehlers-Danlos syndrome in the UK’, Journal of the European Academy of Dermatology and Venereology, 20(10), pp. 1383–1384. Available at: https://doi.org/10.1111/j.1468-3083.2006.01736.x Tofts, L.J. et al. (2023) ‘Pediatric joint hypermobility: a diagnostic framework and narrative review’, Orphanet Journal of Rare Diseases, 18, article 104. Available at: https://doi.org/10.1186/s13023-023-02717-2 Worcestershire Acute Hospitals NHS Trust (2025) Tongue-tie division: information for parents and carers. [Local NHS patient information; confirm the exact title and current URL before publication].

Every infant feeding journey is different. Some families find their rhythm quickly, while others need time, practical help and reassurance as they discover what works for them and their baby. Feeding can change as an infant grows, and what feels manageable one week may feel quite different the next. Breastfeeding, chestfeeding, expressing milk and bottle feeding all bring their own experiences, routines and considerations. The early months can be a time of considerable adjustment for both the infant and the people caring for them. There is no single way that feeding should look, and families should not have to navigate every question or challenge alone. Support is about much more than knowing how to position a baby or understanding how their mouth moves during a feed. Sometimes it means exploring feeding techniques, understanding what an assessment involves or considering the options available. At other times, practical help with everyday life can be just as valuable: someone preparing a meal, doing the washing, looking after other children or taking care of household tasks so that a mother and baby have time to feed, rest and get to know one another. The emotional side of feeding matters, too. The transition into caring for a new baby can bring significant physical and hormonal changes, alongside tiredness, uncertainty and a wide range of emotions. Having someone who will listen without judgement, acknowledge how things feel and help a family find the right support can make a real difference. Community and connection are also important parts of infant feeding support. Speaking with other families can help people feel less isolated, share experiences and realise that they are not the only ones finding aspects of feeding or early parenthood challenging. Sometimes practical information is what is needed; sometimes it is simply the opportunity to talk with people who understand. At D-Restricted Ltd®, I recognise that clinical care is only one part of the wider picture. Alongside specialist infant feeding and tongue-tie services, I provide education, a weekly infant feeding peer-support group, a Resource Library and ongoing support following appointments and procedures. My experience and approach My healthcare career began in 1999, and I qualified as a registered nurse in 2005. My subsequent experience includes neonatal nursing, specialist tongue-tie practice and international board-certified lactation consultant (IBCLC) work. I have supported families with a wide range of infant feeding experiences, including breastfeeding, chestfeeding, expressing breast milk, bottle feeding and combination feeding. My professional qualifications include nursing degrees and diplomas, specialist infant feeding education and IBCLC certification. I became a tongue-tie practitioner in 2014 and have continued to develop my knowledge through clinical practice, education and professional development. I take time to understand the individual infant, the feeding dyad and the wider family circumstances. Feeding is not simply a matter of observing an infant's mouth; it involves the interaction of anatomy, movement, feeding skills, milk production and transfer, the infant's health and development, and the experience of the person feeding them. My approach is therefore centred on assessment, explanation and shared decision-making. Families should have the opportunity to understand the findings, ask questions and consider the available options without feeling pressured into a particular feeding method or intervention. CQC inspection and regulation D-Restricted Ltd® is registered with the Care Quality Commission (CQC) for its regulated activities. My tongue-tie service was inspected by the CQC and received an overall rating of Outstanding. I am the only tongue-tie practitioner to date to have achieved an overall CQC Outstanding rating for my service. This reflects the rating awarded to the service following inspection, rather than a claim that every individual aspect of care is rated Outstanding. You can read more about the inspection and what it means for the service in my article, What makes a CQC Outstanding tongue-tie service?. I have also written about the regulatory requirements for tongue-tie division in England: Tongue-tie release in England: UK CQC requirements. Services for infants and families 1. Tongue-tie assessment and division Tongue-tie, also known as ankyloglossia, describes a restrictive lingual frenulum that can affect tongue movement. The presence or appearance of a frenulum alone does not establish whether division is appropriate. Assessment needs to consider the infant's tongue function, feeding experience, clinical history and the potential benefits and risks of treatment. My tongue-tie appointments include a clinical assessment and discussion of the findings. Where division is considered appropriate, I explain the procedure and the available alternatives so that families can make an informed decision. Division may be undertaken during the same appointment when appropriate, or deferred if the family would prefer more time to consider their options. My approach does not assume that every infant with a tongue-tie needs a procedure. Conservative management and feeding support may be appropriate, depending on the individual assessment. Further reading: Tongue-tie: understanding assessment, feeding, treatment and aftercare How is tongue-tie assessed in babies safely? Tongue-tie assessment tools: appearance, function and validation Tongue-tie or lip-tie restrictions The effects of an untreated tongue-tie restriction: What does the evidence tell us? Surgical release or conservative management for my baby's tongue-tie 2. Infant feeding support: breastfeeding, chestfeeding and bottle feeding Not every feeding journey follows the same path, and feeding preferences and needs can change over time. I offer individual infant feeding support for families who would like help understanding their baby's feeding, exploring practical adjustments or discussing concerns about how feeding is going. Appointments can include observation of a feed, discussion of positioning and attachment, consideration of feeding patterns and milk transfer, and exploration of the techniques that may be helpful for the individual infant and caregiver. Support is available for breastfeeding, chestfeeding, expressed breast milk, infant formula and combination feeding. Bottle feeding also involves more than choosing a bottle. The teat, flow, position, pacing and the infant's ability to coordinate sucking, swallowing and breathing can all be relevant. Where a family is expressing milk, support may include practical considerations around expressing and the use of a breast pump. Further reading: Breastfeeding latch and positioning How to improve infant latch: practical breastfeeding support Bottle feeding positions Choosing Bottles and Teats How to make up a formula bottle safely How to express breastmilk Increasing breast milk production 3. Tongue-tie review, wound review and additional feeding support Following tongue-tie division, families may have questions about healing, changes in feeding and what to expect as their infant recovers. Review appointments can provide an opportunity to discuss these concerns, assess the infant's current presentation and consider whether additional feeding support may be helpful. A wound review is not simply a check of how the frenulum looks. The infant's comfort, feeding function, recovery and the family's experience all form part of the wider picture. Where feeding remains difficult, further assessment can help identify what may need attention rather than assuming that the procedure itself explains every ongoing concern. Additional feeding support may also be useful for families who need more time to explore positioning, attachment, bottle feeding or other aspects of their infant's feeding journey. Further reading: Beyond the tongue-tie release: why aftercare matters Wound healing in infants after a tongue-tie release Tongue-tie release exercises What if a tongue-tie release has not worked? How to improve infant latch: practical breastfeeding support 4. Breast pump flange fitting A breast pump flange is the part of the pump that fits over the nipple and breast. Its fit can affect comfort and how effectively milk is removed during expressing. Flange fitting is not just about measuring nipple diameter: the shape of the flange, the relationship between the nipple and tunnel, the movement of tissue during pumping, comfort and milk removal also need to be considered. I offer flange-fitting appointments to help assess fit and explore the options available for the individual person and pump. The aim is to support comfortable and effective expressing, taking into account the person's anatomy, pumping experience and feeding goals. Further reading: Breast pump flange fitting: assessment explained Breast pump flange fitting: size, shape, comfort and milk removal Flange-fit assessment: what good fit considers How to express breastmilk Types of breast pumps 5. YTM® Tool Method: Tension & Tone The YTM® Tool Method is a prescribed programme of exercises designed to support aspects of orofacial function. The infant protocol considers the mouth, facial structures, soft tissues and the wider body, recognising that feeding involves coordinated movement and function rather than the tongue acting in isolation. The Tension & Tone programme is available for infants with identified functional needs and is not restricted to infants with tongue-tie. Following assessment, individual goals are established and exercises are prescribed according to the findings. The caregiver completes the prescribed exercises three times daily throughout the programme. The programme consists of six sessions delivered over ten weeks, with approximately two weeks between sessions. Progress is reviewed throughout, with an evaluation of the original goals at the final session. The infant YTM® Tool Method programme is suitable up to two years of age where appropriate to the infant's presentation and clinical needs. Further reading: The YTM® Tool Method for infants Tongue function exercises for strength, tone and motility 6. YTM® Tool Method: Tongue-tie, Tension & Tone The Tongue-tie, Tension & Tone programme combines tongue-tie assessment and, where indicated and consented to, surgical division with the YTM® Tool Method programme. It brings together consideration of tongue function, feeding and the wider functional needs identified during assessment. The programme consists of six sessions over ten weeks, with approximately two weeks between sessions. Individual goals are established and exercises are prescribed according to the assessment findings. The caregiver completes the prescribed exercises three times daily throughout the programme. The decision about division is made following clinical assessment and discussion of the potential benefits, risks and alternatives. The YTM® Tool Method can support identified aspects of orofacial function, but it does not replace the clinical decision-making required when considering tongue-tie division. The upper age limit for the YTM® Tool Method programme is two years. The eligibility limit for tongue-tie division is different: division must take place before the infant's first birthday or the eruption of the upper teeth, whichever occurs first. Suitability for division is determined through individual assessment and the service's clinical criteria. Further reading: Tongue-tie: understanding assessment, feeding, treatment and aftercare How is tongue-tie assessed in babies safely? Are you tongue-tie release-ready? Surgical release or conservative management for my baby's tongue-tie The YTM® Tool Method for infants Aftercare and ongoing support Support does not end when an appointment finishes. Families may need time to put information into practice, observe how their infant responds and work through questions as their feeding journey develops. I recognise the value of having continued access to guidance, rather than leaving families to remember everything discussed during a single appointment. Following tongue-tie division, six weeks of virtual aftercare support is included. The support available is designed to help families understand what to expect, access relevant information and ask questions as they navigate the weeks following the procedure. Ongoing support is also an important part of the YTM® Tool Method programmes. Caregivers receive instructions for prescribed exercises and can refer back to programme information between sessions. Progress is reviewed throughout the programme, with the final evaluation considering the goals established at the outset. The Feeding Journey Package and dedicated communications platform The Feeding Journey Package provides a structured way for families to access ongoing support and information. A dedicated communications platform is the preferred method for contacting me between appointments, keeping messages and relevant information together in one place. The package includes access to support guidance, information about what to expect following tongue-tie division, exercise information where relevant to the care plan, and a range of additional resources. It is designed to help families revisit guidance when they need it, rather than relying on memory alone. Having access to written information and a dedicated way to ask questions can be particularly useful when families are tired, managing frequent feeds or trying to remember several pieces of advice at once. It also allows support to remain connected to the infant's individual care journey. Practical information and education The information provided to families is intended to complement individual care, not replace it. General articles and videos can help explain concepts and provide background information, while appointments allow the discussion to focus on the individual infant and feeding dyad. Families can access further information through the Resource Library, the video education available as part of the support package and the weekly infant feeding peer-support group. These options provide different ways to engage with information and support according to individual needs. Weekly infant feeding peer-support group I run a weekly infant feeding peer-support group for families in Leicestershire during confirmed term-time dates. The group provides an opportunity to meet other families, talk about infant feeding and share experiences in a welcoming environment. Support is available for different feeding methods and is not limited to breastfeeding or to infants with tongue-tie. Families and caregivers can ask questions, discuss practical experiences and connect with others who are also caring for a baby. The group is free to attend, and there is no mandatory charge. However, room hire and refreshments cost money, and the group currently operates at a financial deficit. Voluntary contributions are therefore important in helping to cover these costs and keep the group running. Contributions are welcomed but are never a condition of attending. Tongue-tie assessment and division are not performed at the group, and the setting is not appropriate for clinical assessment of an individual infant. Families seeking an individual assessment can find information about the relevant appointments through the D-Restricted Ltd® website. Confirmed group dates and further details are available on the Weekly infant feeding support group page. The Resource Library My Resource Library brings together articles about infant feeding, tongue-tie and related subjects. It is intended to help families explore topics in more detail, revisit information after an appointment and develop a better understanding of the options available to them. The library covers a broad range of subjects, including: Infant feeding, including breastfeeding, chestfeeding, expressed breast milk, infant formula, bottles and teats. Tongue-tie assessment, treatment, conservative management and aftercare. Manual and body therapies that may be used to support tension release affecting feeding. Expressing breast milk, breast pump use and flange fitting. Feeding difficulties, feeding positions, attachment, milk transfer and feeding patterns. The role of healthcare professionals in infant feeding, including their different areas of expertise and how families can find appropriate support. The articles are written to provide information and explain clinical concepts, including areas where the evidence is developing or where outcomes cannot be guaranteed. They are not a substitute for individual assessment, but they can help families prepare questions, understand terminology and make more informed decisions. Video guidance The Feeding Journey Package also includes six video presentations covering subjects relevant to infant feeding and early development: Lactation presentation Introducing Solids presentation An informative guide to 'tongue-tie' before a surgical release Baby Massage presentation Baby Yoga presentation Toddler Yoga presentation These presentations offer another way for families to access information and revisit topics at a time that suits them. They complement the written information in the Resource Library and the individual support available through D-Restricted Ltd®. Professional education and training Alongside my clinical work with infants and families, I provide online education for healthcare professionals through Tongue-tie School. The course is designed for professionals who want to develop their understanding of infant tongue-tie anatomy, function and treatment considerations. The course is entitled Fundamentals in Infant Tongue-tie Anatomy, Function & Treatment Considerations. It is a self-paced online course, with approximately ten hours of core learning alongside additional reading and self-directed study. There is no set timeframe for completion. It is suitable for a range of healthcare and infant feeding professionals, including IBCLCs, nurses, midwives, health visitors, breastfeeding supporters, counsellors, doulas, speech and language therapists and other allied healthcare professionals. The six modules cover: 1. Anatomy and Physiology 2. Potential Impact of Oral Ties and Functional Considerations Over Time 3. Tongue Function Assessment Tools and Differential Diagnosis 4. Body Therapies, Tongue Exercises and Sensorimotor Oral Activities 5. Surgical Release Procedures: Methods, Risks and Clinical Considerations 6. Conservative Management and Ongoing Care The course includes module quizzes, with an 80% pass mark, and a reflective case study. Learners receive ongoing access to the course materials and a dedicated support community. The course is awarded 8 CERPs by IBLCE and 15 CPD points by Advantage. It provides evidence-informed education about anatomy, function and treatment considerations; it does not teach a specific tongue-tie assessment tool or a technique for performing frenulotomy. Further information about the course and enrolment is available through Tongue-tie School. D-Restricted Ltd®: care and support throughout the feeding journey At D-Restricted Ltd®, I recognise that each infant and family brings their own circumstances, concerns and goals. My services combine specialist clinical assessment with practical infant feeding support, ongoing aftercare, education and opportunities for families to connect with others. From tongue-tie assessment and division to feeding support, flange fitting and the YTM® Tool Method programmes, my aim is to help families understand their options and access care that is appropriate to their individual needs. The Resource Library, video education, peer-support group and dedicated communications platform provide additional ways to access information and support beyond an individual appointment. Every feeding journey is different. Families deserve clear information, respectful care and support that recognises both the clinical and everyday realities of feeding and caring for an infant.

Responsive feeding is a biologically normal way of feeding and interacting with a baby. Previously commonly described as demand feeding, it recognises that babies communicate their needs and that feeding works best when caregivers respond to those communications rather than expecting every baby to follow a fixed timetable. A baby may signal readiness to feed, seek closeness, need comfort or communicate that they have had enough. The caregiver observes these signals, offers milk when appropriate and responds to the baby’s behaviour during the interaction. The baby, in turn, responds to the offer. This makes feeding a two-way process rather than something directed entirely by either the clock or the adult. Responsive feeding does not mean waiting for a baby to cry before offering milk, nor does it mean that the baby must initiate every feed. A lactating parent may offer the breast because their breasts feel full, because they are about to go out or because they would like to sit down and feed their baby. The baby can accept or decline the opportunity, and the interaction continues from there. This approach recognises that babies are individuals. They do not necessarily feed at the same intervals, take the same volumes or behave in the same way at every feed. Their needs change with age, development, health and circumstances. Responsive feeding allows for this variation while keeping the baby’s nutritional needs and the caregiver’s experience in view. What does responsive feeding mean? Responsive feeding involves recognising and responding to a baby’s signals throughout the feeding interaction. These may relate to hunger, readiness to feed, comfort, the need for a pause or fullness. The term is used across different feeding methods, including breastfeeding, chestfeeding, feeding expressed breast milk and infant formula by bottle, and combination feeding. The practical details differ, but the central principle remains: observe the baby, offer appropriate feeding opportunities and respond to their behaviour without unnecessary pressure. The World Health Organization’s (WHO) 2023 guideline specifically addresses responsive feeding during complementary feeding from six months of age. UNICEF UK’s Baby Friendly Initiative also provides guidance on responsive feeding in early infancy, including breastfeeding and bottle feeding (WHO, 2023; UNICEF UK Baby Friendly Initiative, 2017). Responsive feeding is sometimes misunderstood as allowing a baby to determine every aspect of feeding without adult involvement. In reality, the caregiver remains responsible for offering feeds, providing safe and appropriate milk, recognising when additional support may be needed and ensuring that the baby’s nutritional requirements are met. It is also different from simply feeding whenever a baby cries. Crying can be a late hunger cue, but it can also communicate tiredness, discomfort, overstimulation or a need for closeness. Looking at the wider context helps caregivers decide how best to respond. Recognising feeding cues Babies communicate through behaviour from birth. They may show early signs of readiness to feed through stirring, rooting, opening their mouths or bringing their hands towards their mouths. As hunger increases, they may become more restless or vocal. During a feed, babies may actively suck and swallow, pause, change their sucking pattern, turn away, relax or stop feeding. These behaviours provide information about how the feed is progressing and whether the baby wants to continue. Cues are not a rigid checklist. The same behaviour can have different meanings depending on the baby’s age, alertness, recent feeding, environment and individual characteristics. A baby bringing their hands to their mouth may be hungry, but they may also be exploring their hands or seeking comfort. A baby looking away may need a pause, may have had enough or may simply be distracted. Caregivers become familiar with their own baby’s patterns over time. There is no expectation that every cue must be interpreted correctly on every occasion. For a more detailed explanation of early feeding cues and how to recognise them, see Recognising Feeding Cues in Young Babies. Feeding for comfort as well as nutrition Babies seek feeding for reasons beyond satisfying hunger. Sucking, physical closeness, warmth and the familiar interaction of feeding can provide comfort and reassurance. A baby may seek the breast when tired, unsettled or in need of closeness. They may want to suck without transferring much milk, or they may feed for a combination of nutritional and comforting reasons. These needs are not mutually exclusive: a baby can be hungry and also seek reassurance. Offering the breast for comfort is not a bad habit, and a baby cannot be spoiled by receiving appropriate comfort and attention. Feeding is one of the ways babies experience closeness and learn that their communications receive a response (UNICEF UK Baby Friendly Initiative, 2017). Bottle feeding can also be a source of closeness and reassurance. Holding the baby close, maintaining eye contact where welcomed, allowing pauses and responding to their signals can make feeding a positive relational experience, whether the bottle contains expressed breast milk or infant formula. At the same time, not every unsettled period requires milk. A baby may benefit from being held, reduced stimulation, help settling or another appropriate response. Responsive care involves considering what the baby may be communicating rather than automatically assuming that every cry indicates hunger. Responsive feeding and maternal breast fullness Responsive feeding is not restricted to situations in which the baby initiates a feed. A lactating parent can also initiate an offer in response to their own physical needs or practical circumstances. For example, breasts may become full and uncomfortable as milk production increases in the early days after birth. Offering the breast gives the baby an opportunity to feed and may help relieve some fullness if the baby is ready to feed. The baby’s response remains important. They may accept the offer and feed, or they may show little interest. The caregiver does not need to force a feed simply because their breasts are full, nor do they need to wait for the baby to become distressed before offering the breast. Engorgement can cause swelling and tightness around the nipple and areola, making attachment more difficult. If the baby struggles to attach, gentle hand expression or reverse pressure softening may help soften the area around the nipple. Persistent or severe pain, redness, fever or flu-like symptoms warrant appropriate clinical advice. For more information, see Reverse Pressure Softening Technique for Engorgement. This is an example of the reciprocal nature of responsive feeding: the parent may initiate the opportunity, the baby responds, and the parent then adapts to the baby’s response. There is also a hormonal connection between feeding and milk production. Suckling stimulates the release of prolactin, which supports milk synthesis, and oxytocin, which triggers milk ejection; frequent, effective milk removal helps regulate ongoing milk production (WHO, 2009). Why feeding to a set schedule is not usually appropriate Historically, feeding a baby at prescribed intervals was often described as routine or scheduled feeding. Responsive feeding recognises that babies have individual needs and that these do not necessarily fit a timetable. A baby’s stomach is small, particularly in the newborn period, and breast milk is digested relatively quickly. Babies may therefore need to feed frequently, sometimes with several feeds close together followed by a longer interval. Their needs can vary throughout the day and change as they grow. Expecting every baby to feed at the same times, for the same duration or at fixed intervals does not reflect this normal variation. For a breastfeeding parent, restricting feeds to a timetable can also affect milk production. Milk production responds to milk removal: frequent, effective milk removal helps signal the breasts to continue producing milk. Delaying feeds to make a baby wait for the next scheduled time, or routinely limiting feeding opportunities, may reduce milk removal and compromise supply. This is particularly relevant while lactation is being established (UNICEF UK Baby Friendly Initiative, 2017; WHO and UNICEF, 2018). Responsive feeding allows the baby to feed when they show signs of readiness rather than requiring them to wait until a designated time. It also recognises the lactating parent’s needs. A parent may offer the breast because their breasts are uncomfortably full, because they would like to feed before going out or because they want to sit down and spend time with their baby. The same principle applies to bottle feeding. Although caregivers may use guidance about typical milk volumes, babies should not be expected to finish a bottle simply because a particular amount has been prepared. A baby who turns away, relaxes or stops actively feeding may be communicating that they have had enough or need a pause. Equally, a baby may show signs of wanting more. When a feeding schedule is medically necessary Responsive feeding does not mean that feeding plans, prescribed volumes or scheduled feeds are never appropriate. Some babies need additional structure because of their clinical circumstances. For example, a premature or very sleepy newborn, a baby with hypoglycaemia or significant jaundice, or an infant with concerns about milk transfer, hydration or weight gain may need to be woken for feeds, offered feeds at specified intervals or given measured supplementary volumes. In these circumstances, the feeding plan should be based on the baby’s individual needs and guided by the healthcare professionals responsible for their care. The plan may specify minimum feeding frequency, maximum intervals between feeds, supplementary volumes or other measures to ensure adequate intake. These instructions should not be replaced by cue-led feeding alone when doing so could put the baby’s health at risk. Where breastfeeding is being established or maintained, the plan should also consider how milk production will be protected if the baby is unable to feed effectively or frequently enough at the breast. This may involve hand expression or pumping alongside an agreed plan for providing sufficient milk. A medically indicated schedule is different from imposing a routine for convenience or expecting all babies to follow the same pattern. Where a structured plan is necessary, it should be reviewed as the baby’s clinical condition and feeding effectiveness change, with the aim of meeting the baby’s nutritional needs while supporting responsive interaction wherever possible. For information about newborn feeding patterns and signs that additional support may be needed, see Newborn feeding: Signs your baby may need extra support. Bottle feeding, paced feeding and recommended volumes Responsive feeding applies to bottle feeding as well as feeding directly at the breast or chest. The caregiver offers milk and provides support, while the baby communicates readiness, engagement, the need for a pause and when they have had enough. Paced bottle feeding is one way of supporting this interaction. Holding the baby close, keeping the bottle relatively horizontal and allowing pauses gives the baby opportunities to coordinate sucking, swallowing and breathing and to communicate whether they wish to continue. The intention is not to slow every feed to a prescribed duration, but to avoid milk flowing continuously into the baby’s mouth and to respond to their individual feeding rhythm. See How to pace bottle feeds: a calm, practical guide for a practical explanation. Formula-feeding guidance often provides suggested volumes and feeding frequencies according to a baby’s age. These figures are useful as an average guide, but they are not a personalised calculation of what every baby needs at every feed. Babies differ in size, appetite, feeding patterns and energy requirements. A baby may take different amounts at different feeds, feed little and often, or need a different pattern from the one suggested in a table. First Steps Nutrition Trust’s A Simple Guide to Infant Milks provides approximate guidance on page 17, based on average energy requirements and average infant weights. These figures should be used as a guide rather than a target that every baby must meet (First Steps Nutrition Trust, 2020, p. 17). See First Steps Nutrition Trust’s guide to infant milks. A baby should not be pressured to finish a bottle simply because a recommended volume has been prepared. Equally, consistently low intake should not be dismissed as the baby regulating their own appetite without considering growth, hydration and overall health. Responsive feeding means interpreting cues alongside the wider clinical picture, not using cues as a substitute for assessing whether a baby is receiving enough milk. Where a baby has a medical reason for a prescribed intake, such as prematurity, hypoglycaemia, significant jaundice, inadequate milk transfer or concerns about growth, an individualised plan may specify volumes, feeding intervals or minimum intake. In these circumstances, the plan should be followed and reviewed by the healthcare team, while continuing to offer feeds as responsively as the baby’s condition allows. The distinction is between using average volumes to inform feeding and treating them as compulsory amounts for every baby. Responsive bottle feeding respects the baby’s communication while ensuring that their nutritional and medical needs are met. Feeding patterns during growth and development Babies do not follow a perfectly predictable feeding schedule. Their needs and behaviour change as they grow, and feeding patterns can vary from one day to the next. Some babies have periods of more frequent feeding, sometimes described as cluster feeding. This can occur during early infancy and at other times. Changes in feeding frequency may coincide with growth, changes in alertness, sleep, stimulation or behaviour, but a change in feeding frequency alone cannot establish that a baby is experiencing a growth spurt. Development brings changes in awareness, movement, communication and interest in the surrounding world. A baby who previously fed with few distractions may begin looking around, pausing frequently or becoming more easily distracted. Another baby may seek additional closeness or feeds when tired or unsettled. Families may also encounter the term developmental leaps, particularly in relation to the popular Wonder Weeks concept. Although babies undoubtedly undergo developmental changes, the idea that these produce a fixed, predictable sequence of unsettled periods at specific ages should not be treated as an established clinical timetable. Individual development and behaviour vary, and a change in feeding does not necessarily identify a particular developmental stage. A temporary increase in feeding can be normal, but it should not automatically be attributed to growth or development. A baby who feeds almost continuously, rarely seems satisfied, repeatedly falls asleep before feeding effectively, has fewer wet nappies than expected or is not gaining weight appropriately may need an individual feeding assessment. Responsive feeding involves remaining open to normal variation while recognising when a pattern deserves further investigation (NHS, n.d.-a; UNICEF UK Baby Friendly Initiative, 2017). When and where to seek feeding support Responsive infant feeding is not a substitute for monitoring health. Families should seek prompt advice from an appropriate healthcare professional if a baby is difficult to wake for feeds, refuses several feeds, has noticeably fewer wet nappies than usual, shows signs of dehydration, has worsening jaundice, vomits repeatedly, has breathing concerns or is not gaining weight as expected. Urgent concerns should be assessed through local urgent care services. A feeding review is also valuable when feeding has become painful, exhausting or emotionally difficult, even if growth appears satisfactory. Weight is one important measure, but it is not the whole feeding story. A caregiver’s pain, confidence, mental wellbeing and ability to continue with their chosen feeding plan matter too. Different professionals provide different types of infant feeding support. Peer supporters can offer encouragement, practical information and a listening ear. Breastfeeding counsellors provide more extensive breastfeeding-specific support. Midwives, health visitors and other healthcare professionals can support feeding within their professional roles. For more complex or persistent feeding concerns, an appropriately qualified infant feeding specialist or International Board Certified Lactation Consultant (IBCLC) may be able to undertake a more detailed assessment. An IBCLC has met defined requirements for lactation-specific education, clinical experience and examination. Their specialist knowledge covers a wide range of feeding situations, including breastfeeding, expressing, bottle feeding, infant formula, combination feeding and changing feeding methods. The IBCLC credential does not replace medical care, but it can complement it by providing specialist assessment and support related to lactation and infant feeding. The appropriate professional depends on the concern. Medical symptoms may require assessment by a GP, paediatrician or another healthcare professional. Feeding support may involve observing a feed, considering milk transfer, reviewing bottle-feeding techniques, discussing expressing or exploring the interaction between feeding, infant behaviour and caregiver wellbeing. For more information, see What does an infant feeding specialist do? and What is an IBCLC? Feeding Support Explained. Seeking support does not mean that responsive feeding has failed. It means recognising when additional knowledge, assessment or practical help could benefit the baby and family. The aim is to understand what is happening, identify any needs that require attention and help families find a safe and sustainable way forward. Conclusion Responsive feeding recognises that feeding is both a biological process and a relationship. Babies communicate their needs, caregivers offer opportunities to feed and respond to the baby’s behaviour, and feeding patterns adapt as the baby grows. Sometimes the response will be to offer milk. Sometimes the baby will communicate that they do not want it, need a pause or have finished. At other times, the caregiver may initiate an offer because of breast fullness or another practical consideration, then respond to the baby’s reaction. Feeding is neither entirely directed by the infant nor controlled by the adult. It is an interaction in which both matter. Families do not need to interpret every movement perfectly or worry that every feed must follow a particular pattern. The aim is to respond with care, recognise individual needs and seek skilled support when feeding effectiveness, growth or wellbeing raises concerns. Every feeding journey deserves support that respects the infant’s cues, the caregiver’s experience and the many factors that shape feeding. References First Steps Nutrition Trust (2020) A simple guide to infant milks. March 2020, p. 17. Available at: https://www.firststepsnutrition.org/s/Infantmilksasimpleguide_March2020a.pdf National Health Service (NHS) (n.d.-a) Breastfeeding: the first few days. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/the-first-few-days/ National Health Service (NHS) (n.d.-b) Feeding on demand. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/feeding-on-demand/ National Health Service (NHS) (n.d.-c) Milk supply. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/breastfeeding-challenges/milk-supply/ Pérez-Escamilla, R., Segura-Pérez, S., Lott, M. and the RWJF HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers from Birth to 24 Months (2017) ‘Responsive feeding: Promoting healthy growth and development for infants and toddlers’, Current Developments in Nutrition, 1(11), e001206. https://doi.org/10.3945/cdn.117.001206 UNICEF UK Baby Friendly Initiative (2017) Responsive feeding infosheet. Available at: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/relationship-building-resources/responsive-feeding-infosheet/ Ventura, A.K. and Birch, L.L. (2008) ‘Does parenting affect children’s eating and weight status?’, International Journal of Behavioral Nutrition and Physical Activity, 5, article 15. https://doi.org/10.1186/1479-5868-5-15 World Health Organization (WHO) (2009) Infant and young child feeding: Model chapter for textbooks for medical students and allied health professionals. Geneva: WHO. Available at: https://www.ncbi.nlm.nih.gov/books/NBK148970/ World Health Organization (WHO) (2018) Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative. Geneva: WHO. Available at: https://www.unicef.org/media/95191/file/Baby-friendly-hospital-initiative-implementation-guidance-2018.pdf World Health Organization (WHO) (2023) WHO guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789240081864

Fascia is a form of connective tissue that surrounds, supports and connects structures throughout the body. The term is used in different ways across anatomical and clinical disciplines, so it is important to distinguish individual fascial tissues from the wider fascial system (Adstrum et al., 2017; Schleip et al., 2019). In the mouth, fascia exists alongside muscles, mucosa, glands, nerves, blood vessels and other connective tissues. These structures work together to support movement, stability, sensation and oral function. Understanding their relationships can help explain why an infant’s feeding function should be considered as a coordinated process rather than an isolated movement of the tongue. Interest in fascia and infant feeding has grown alongside wider discussion of oral function, tongue-tie and body-based approaches to care. However, anatomical relationships, plausible mechanisms and demonstrated clinical outcomes are not interchangeable concepts. Understanding what the anatomy shows — and how this relates to feeding assessment — is essential for both healthcare professionals and families. Oral anatomy: muscle, fascia and mucosa Muscle Muscles generate active force. They contract and relax to move or stabilise structures, with their activity coordinated by the nervous system. The tongue contains intrinsic and extrinsic muscles. Intrinsic muscles alter its shape, while extrinsic muscles help move it in different directions. Tongue movement also involves the floor of the mouth, mandible, hyoid region and associated structures. These relationships are relevant to the coordinated movements required for sucking, swallowing and other oral functions (Dotiwala and Samra, 2023). During infant feeding, tongue movement does not occur in isolation. Jaw movement, lip and cheek activity, oral sensation, breathing and swallowing all contribute to the feeding sequence. The effectiveness of this coordination varies with the infant’s developmental stage, state of alertness, feeding method and individual anatomy. Fascia Fascia is connective tissue containing collagen and other extracellular components. Depending on its location, it can surround, separate, support or connect anatomical structures. Fascial tissues vary in thickness, composition, arrangement and mechanical properties (Adstrum et al., 2017). Within the mouth, fascial tissues are found beneath the oral mucosa and in association with the tongue, floor of the mouth and surrounding structures. They help provide structural support while allowing tissues to move in relation to one another. Fascia is not simply an inert wrapping around muscles. Its properties contribute to the way forces are distributed through tissues, and fascial structures may contain sensory nerve endings. Nevertheless, the specific contribution of an individual fascial layer depends on its anatomy, location and function. Fascia, myofascia and connective tissue The term myofascia generally describes the relationship between muscle and its associated fascial tissues. It is useful when discussing how muscular activity interacts with surrounding connective tissue, although it should not be taken to mean that all muscle and fascia form one uniform structure. Connective tissue is the broader category. It includes several different tissue types, such as tendons, ligaments, cartilage, bone and the connective tissue layers associated with muscles and organs. Fascia and ligaments are therefore not interchangeable terms, even though ligaments may be included within broad definitions of the fascial system (Adstrum et al., 2017). These distinctions matter when discussing infant feeding. A muscle produces active movement; fascia contributes to structural support and mechanical relationships; and the mucosa provides a protective, sensory surface. These tissues interact, but they do not perform identical functions. Fascia, myofascia and connective tissue: key distinctions These terms are related, but they are not interchangeable. | Term | Meaning | Example | |---|---|---| | Connective tissue | A broad category of tissues that support, connect or protect other structures | Fascia, tendons, ligaments and cartilage | | Fascia | An identifiable connective tissue structure that surrounds, supports, encloses or separates other structures | Connective tissue surrounding a muscle | | Myofascia | A term generally used for fascia associated with muscle | Connective tissue associated with muscle fibres and muscle groups | | Tendon | Connective tissue that transmits force between a muscle and its attachment | A tendon connecting muscle to bone | | Ligament | Connective tissue that connects bones or helps stabilise joints | A ligament supporting a joint | | Mucosa | A membrane lining a body surface or cavity that communicates with the exterior | The lining of the mouth | Mucosa The oral mucosa is the moist lining of the mouth. It provides a protective barrier and contributes to sensation. Its structure varies according to location and function, with specialised areas of the mouth adapted to different mechanical demands (Brizuela and Samra, 2023). Mucosa is not the same as fascia. Although the two tissues lie closely together in some regions, they differ in their organisation and function. The mucosa forms the surface lining, while underlying connective tissue and fascia provide support and contribute to the movement of deeper structures. The distinction is particularly important when considering the lingual frenulum, which is formed through the relationship between the oral mucosa and underlying floor-of-mouth fascia. For further reading on the structures involved, see Infant Oral Anatomy: Structure, Function and Feeding. The lingual frenulum: mucosa and fascia together The lingual frenulum is often described in everyday language as a band of tissue beneath the tongue. Anatomical research has provided a more detailed explanation of its structure. Mills et al. (2019a) examined the lingual frenulum and floor of the mouth in adult cadavers. Their findings described the frenulum as a dynamic fold formed when the underlying floor-of-mouth fascia and overlying oral mucosa move with the tongue. The fascia extends across the floor of the mouth and has relationships with the tongue and surrounding structures. A subsequent study examined the neonatal lingual frenulum. Mills et al. (2019b) found a layered structure involving oral mucosa and underlying floor-of-mouth fascia, with the fascial layer contributing to the fold seen during tongue elevation or retraction. These findings help explain why the appearance of the frenulum can change with tongue movement and why it should not be understood simply as a discrete string or cord. They also demonstrate that the tissues beneath the tongue are anatomically connected with structures around the floor of the mouth. This anatomical understanding is relevant to tongue-tie assessment. However, the appearance of a frenulum alone does not establish whether tongue mobility is functionally restricted. Assessment needs to consider movement and feeding function alongside anatomy. For a more detailed discussion, see How Is Tongue Tie Assessed in Babies? and What Does a Tongue-tie Assessment Consider?. Oral fascia and infant feeding Infant feeding depends on coordinated movement, sensory feedback and the ability to adapt to the demands of a feed. The tongue, jaw, lips, cheeks, floor of the mouth and surrounding structures contribute to this process, alongside swallowing and respiratory coordination. Fascial tissues provide structural relationships between some of these components. Their arrangement and mechanical properties may influence how tissues move in relation to one another. Where movement is uncomfortable, poorly coordinated or mechanically limited, it is reasonable to consider the relevant muscles, connective tissues and surrounding anatomy as part of the overall assessment. This does not mean that every feeding difficulty is caused by fascial tension, or that the presence of tension establishes a particular diagnosis. Feeding difficulties can have multiple contributing factors, including oral anatomy, muscle function, sensory responses, developmental factors, feeding experience and the practical circumstances of feeding. A whole-feeding assessment therefore needs to establish what is happening during feeding before deciding whether a particular anatomical or movement-related factor is relevant. For families, this is an important distinction: discussion of fascia is not intended to suggest that a hidden tissue problem explains every feeding concern. Rather, it provides another part of the anatomical context in which oral movement and feeding function can be understood. Myofascial connections and whole-body tension Whole-body relationships and myofascial connections The mouth is part of a larger musculoskeletal system. The jaw, head, neck, shoulder girdle and trunk are connected through muscles, connective tissues, joints and the nervous system. Posture and movement in one region can influence the demands placed on another, although the nature and extent of that influence depend on the structures and activities involved. Thomas Myers’ Anatomy Trains model describes proposed myofascial meridians: pathways linking muscles and associated connective tissues into functional lines through the body (Myers, 2020). The model offers a way of considering anatomical continuity and potential relationships between regions rather than treating each muscle as an entirely separate unit. Research has investigated whether mechanical forces can be transmitted between adjacent muscles and connective tissues. Krause et al. (2016) reviewed anatomical dissection studies and in-vivo experiments and found evidence of force transmission at some of the investigated connections. Wilke et al. (2016) also examined anatomical continuity within the myofascial meridians proposed by Myers. These findings support the idea that some musculoskeletal structures are mechanically connected. They do not establish that every proposed pathway functions in the same way in every person, or that a particular area of tension will necessarily cause symptoms in a distant region. Applied to infant feeding, this wider anatomical perspective encourages consideration of how the head, neck, jaw and body move together. An infant’s preferred head position, limited comfortable movement or difficulty maintaining a feeding position may be relevant observations during assessment. They should be interpreted in the context of the infant’s overall presentation rather than automatically attributed to fascial restriction. The concept of whole-body tension is therefore best understood as a way of considering relationships between structures and movement, not as a diagnosis in itself. The Anatomy Trains model provides one framework for exploring these relationships; it should not be used as proof of a specific cause of feeding difficulty. A whole-feeding assessment Understanding oral fascia is most useful when it informs a broader assessment of the infant’s feeding function. The aim is to identify the factors contributing to the presenting difficulty and determine which aspects of care may be appropriate. Depending on the concerns, an assessment may consider: The infant’s oral anatomy, including tongue movement and the relationship between the tongue and floor of the mouth. Tongue, jaw, lip and cheek movement during feeding. Sucking patterns, milk transfer where assessable, swallowing and coordination with breathing. Comfort, endurance and the infant’s ability to sustain feeding. Head and neck movement, positioning and any relevant asymmetry. The feeding environment, feeding method and practical challenges experienced by the feeding dyad. The caregiver’s observations, priorities and goals. Breastfeeding and bottle-feeding assessments need to reflect the different mechanics and practical demands of each method. During bottle feeding, observations may include how the infant attaches to the teat, maintains a seal, coordinates sucking with swallowing and breathing, manages milk flow and sustains feeding comfortably. The teat and bottle flow rate, positioning and pacing may also be relevant. As with breastfeeding, these observations need to be considered alongside the infant’s overall presentation rather than attributing difficulties automatically to oral fascia. An observation of oral movement outside a feed may provide useful information, but it does not replace assessment of the infant feeding. The IBCLC role and infant feeding support and What Does an Infant Feeding Specialist Do? explain how specialist feeding support can help identify and address functional difficulties. Relevant assessment findings may also indicate the need for input from other appropriately qualified healthcare professionals. Where tongue-tie is being considered, the assessment should establish whether restricted tongue movement is contributing to feeding difficulty rather than relying on frenulum appearance alone. The Academy of Breastfeeding Medicine position statement emphasises the importance of a skilled breastfeeding assessment and functional evaluation when considering ankyloglossia in breastfeeding dyads (LeFort et al., 2021). A whole-feeding assessment helps determine whether movement-related concerns are relevant, whether additional assessment is needed and which interventions are appropriate to the individual infant. Manual therapies and infant feeding Manual and body-based approaches encompass a range of practices, including osteopathic and other hands-on therapies. The techniques, training requirements and clinical frameworks differ, so they should not be treated as one uniform intervention. Depending on the assessment and the practitioner’s scope of practice, an approach may aim to support comfortable movement, address excessive muscular tension, improve the movement of relevant tissues or help an infant tolerate functional positions. These aims need to be connected to observable findings and the infant’s feeding goals. Manual techniques and strengthening exercises are not the same intervention. Strengthening requires appropriate muscular activation and loading. Neuromuscular re-education involves learning or refining movement through sensory input, motor activity, coordination and practice. Depending on the infant’s needs, these approaches may be considered separately or alongside one another. Research into manual therapies and infant feeding includes studies of different designs and quality. Fons et al. (2026) reported a randomised, controlled pilot study examining osteopathic manipulative treatment as an adjunct to lactation support for healthy, full-term newborns identified by an IBCLC as having feeding dysfunction. The study contributes to the developing literature, but its pilot design and specific protocol mean that its findings should not automatically be generalised to every manual therapy, infant population or feeding concern. Clinical decisions should therefore be based on the infant’s individual assessment, the practitioner’s training and scope of practice, and the intended functional outcomes. Manual or body-based approaches should complement appropriate feeding support rather than replace it, and persistent or concerning feeding difficulties require appropriate clinical assessment. My related articles explore these approaches in more detail: Manual Therapy and Infant Feeding, Infant Body Therapies and the Connection to Infant Feeding and Infant Skull Shape and Infant Feeding. Home-based activities and daily repetition Home-based techniques demonstrated by a suitably qualified practitioner may form an important part of a programme. When families are shown how to carry out appropriate exercises or activities safely and correctly, regular daily repetition provides opportunities to practise and reinforce targeted movements between appointments. Depending on the intervention, this practice may support motor learning, muscular function and neuromuscular re-education. Techniques should be appropriate to the infant’s developmental stage, clearly explained and reviewed by the practitioner to ensure they remain suitable and contribute to the intended functional goals. Families should not be expected to perform techniques that have not been demonstrated clearly or that cause the infant distress. The YTM® Tool Method is one example of an approach incorporating practitioner-led sessions alongside prescribed home exercises. In this type of programme, regular practice forms part of the intervention rather than being an incidental addition to appointments. Home activities do not replace a feeding assessment or the need to review progress. Their purpose is to provide appropriate opportunities for practice between sessions, with the programme adjusted according to the infant’s response and functional goals. Tongue-tie and feeding function Tongue-tie, or ankyloglossia, concerns restricted tongue movement associated with the lingual frenulum. The relevance of the frenulum to feeding depends on its effect on function, not simply its appearance. The anatomical work by Mills et al. (2019a, 2019b) helps explain the relationship between the lingual frenulum, floor-of-mouth fascia and overlying mucosa. It also provides context for understanding why the frenulum changes appearance during movement. However, anatomical description alone does not establish whether an infant has functionally significant restriction. When tongue-tie is suspected, assessment should consider tongue mobility and feeding function, including whether the observed difficulties are plausibly related to restricted movement. Other factors that may affect feeding should also be considered. Where a frenulotomy is indicated following appropriate assessment and shared decision-making, it should form part of a wider plan for feeding support and follow-up rather than being considered in isolation. Manual therapies, movement-based approaches and home exercises may be considered where assessment identifies relevant needs, but they are not interchangeable with frenulotomy and should not be assumed to be necessary for every infant with tongue-tie. Equally, frenulotomy alone does not remove the need to assess ongoing feeding difficulties or provide appropriate support. For further reading, see Tongue-tie restriction in babies, Does My Baby Need a Tongue-tie Release? and Choosing Your Tongue-tie Practitioner. Conclusion Fascia is part of the connective-tissue framework that supports the mouth and its relationship with surrounding structures. Within the oral cavity, it exists alongside muscle, mucosa, nerves and glands, with each tissue contributing differently to anatomy and function. Research into the lingual frenulum has demonstrated the importance of the underlying floor-of-mouth fascia and its relationship with the overlying mucosa. Broader research into myofascial connections also supports the existence of mechanical relationships between some adjacent structures, while leaving important questions about their functional significance in particular clinical situations. For infant feeding, these anatomical concepts are most useful when considered alongside observation of feeding, assessment of oral movement and attention to the infant’s wider presentation. Manual therapies and home-based activities may have a role where they are appropriate to the individual assessment and linked to clear functional goals. A whole-feeding approach keeps the focus on the infant’s function and the feeding dyad’s needs, using anatomical knowledge to inform assessment and support rather than assuming that one tissue or one intervention explains every feeding difficulty. References Adstrum, S., Hedley, G., Schleip, R., Stecco, C. and Yucesoy, C.A. (2017) ‘Defining the fascial system’, Journal of Bodywork and Movement Therapies, 21(1), pp. 173–177. doi: 10.1016/j.jbmt.2016.11.003. Brizuela, M. and Samra, N.S. (2023) ‘Histology, oral mucosa’, in StatPearls. Treasure Island, FL: StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK572115/. Dotiwala, A.K. and Samra, N.S. (2023) ‘Anatomy, head and neck, tongue’, in StatPearls. Treasure Island, FL: StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK507782/. Fons, D., Watts, K.B., Vannitamby, H., Rainey, S., Ford-Davis, J., Wang, Y., Van Heukelom, S. and Wright, A. (2026) ‘Osteopathic manipulative treatment for management of feeding dysfunction in breastfed newborns’, Journal of Osteopathic Medicine, 126(8), pp. 383–391. doi: 10.1515/jom-2024-0133. Krause, F., Wilke, J., Vogt, L. and Banzer, W. (2016) ‘Intermuscular force transmission along myofascial chains: a systematic review’, Journal of Anatomy, 228(6), pp. 910–918. doi: 10.1111/joa.12464. LeFort, Y. et al. (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. doi: 10.1089/bfm.2021.29179.ylf. Mills, N., Pransky, S.M., Geddes, D.T. and Mirjalili, S.A. (2019a) ‘What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum’, Clinical Anatomy, 32(6), pp. 749–761. doi: 10.1002/ca.23343. Mills, N., Keough, N., Geddes, D.T., Pransky, S.M. and Mirjalili, S.A. (2019b) ‘Defining the anatomy of the neonatal lingual frenulum’, Clinical Anatomy, 32(6), pp. 824–835. doi: 10.1002/ca.23410. Myers, T.W. (2020) Anatomy Trains: Myofascial Meridians for Manual Therapists and Movement Professionals. 4th edn. Edinburgh: Elsevier. Schleip, R., Hedley, G. and Yucesoy, C.A. (2019) ‘Fascial nomenclature: update on related consensus process’, Clinical Anatomy, 32(7), pp. 929–933. doi: 10.1002/ca.23423. Wilke, J., Krause, F., Vogt, L. and Banzer, W. (2016) ‘What is evidence-based about myofascial chains: a systematic review’, Archives of Physical Medicine and Rehabilitation, 97(3), pp. 454–461. doi: 10.1016/j.apmr.2015.07.023.

Breast fullness, engorgement and swelling around the nipple can make it difficult for a baby to attach comfortably to the breast. Reverse pressure softening (RPS) is a technique that uses gentle, sustained fingertip pressure to soften the tissue around the nipple and areola. It may be helpful when firm tissue results from milk engorgement, oedema, or a combination of the two (Cotterman, 2004; Berens and Brodribb, 2016). The aim is to make the areola more pliable so that a baby can take the breast into their mouth more easily. Reverse pressure softening does not remove milk from the breast. Instead, it temporarily reduces resistance in the tissue around the nipple, potentially making attachment easier and supporting effective milk transfer. Understanding breast engorgement and areolar oedema Breast engorgement and oedema can occur together, but they are not the same process. Engorgement commonly occurs as milk production increases after birth. This process, known as secretory activation, involves the onset of copious milk secretion following hormonal changes after birth. Breasts may become fuller, heavier and warmer as this process progresses. For some women, swelling is substantial enough to make the areola firm and attachment difficult (Pang and Hartmann, 2007; Berens and Brodribb, 2016). Oedema is swelling caused by excess fluid accumulating in the spaces between tissues. When fluid accumulates around the nipple and areola, the tissue can become tight and less pliable, even when milk volume alone does not explain the degree of firmness (Cotterman, 2004; Kujawa-Myles et al., 2015). To picture oedema, think about swollen feet or ankles during late pregnancy. Sometimes, pressing gently on a swollen area leaves a temporary indentation. This is known as pitting oedema and illustrates how fluid can accumulate within body tissues. Breast oedema does not always pit, however, and breast tissue is different from the tissue around the ankles. The comparison simply helps illustrate the concept of fluid within the tissues; it does not mean that breast oedema will look or feel the same. A breast may therefore feel firm because of milk fullness, tissue oedema, or both. Reverse pressure softening may help soften the area around the nipple, but the wider feeding situation and the cause of the swelling still need to be considered. Why engorgement develops Milk production increases after birth In the first days after birth, secretory activation brings an increase in milk production. Some breast fullness is a normal part of this transition, although excessive or uncomfortable engorgement can make feeding difficult (Pang and Hartmann, 2007; Berens and Brodribb, 2016). Intravenous fluids during labour and birth Intravenous fluids given during labour and around birth may contribute to postpartum fluid retention and breast oedema in some women. A small observational pilot study involving 17 women found greater breast oedema among participants who received intravenous fluids than among those who did not. The researchers concluded that larger studies were needed to investigate the relationship further. The findings cannot establish that intravenous fluids caused the swelling or determine a volume at which fluids become excessive (Kujawa-Myles et al., 2015). This is a possible contributing factor, rather than an explanation for every case of breast engorgement or oedema. Milk is not being removed effectively or frequently enough When a baby cannot attach effectively, feeds are missed or milk removal is less frequent than the baby needs, milk may accumulate and discomfort can increase. If attachment is difficult because the areola is swollen, this can create a cycle: swelling makes attachment harder, while ineffective milk transfer may contribute to continuing fullness. It is important to assess feeding and milk transfer rather than assuming that frequent feeding alone will resolve every problem. If there are concerns about swallowing, the amount of milk being transferred or the baby’s weight, prompt assessment is appropriate. Further information is available in Signs of poor milk transfer in your baby at feeds. Oversupply and excessive expression Producing more milk than a baby needs can contribute to persistent fullness and discomfort. Regularly expressing substantially more milk than is needed may also stimulate further milk production in some circumstances. The approach to oversupply should be individualised, because abruptly reducing milk removal can create other problems and may not be appropriate for everyone (Johnson et al., 2020). See Increasing breast milk production for further information about milk production and the importance of understanding the reason for a supply concern before making changes to feeding or expressing. Why reverse pressure softening can help The tissue beneath and around the areola needs to be sufficiently pliable for a baby to attach deeply. When this tissue becomes swollen and firm, the nipple and areola may be more difficult for a baby to grasp. This can contribute to attachment difficulties, nipple discomfort and ineffective milk transfer (Cotterman, 2004). Reverse pressure softening uses gentle, sustained pressure around the base of the nipple to temporarily move some of the swelling away from the immediate areolar area and further into the breast tissue. The Academy of Breastfeeding Medicine describes the technique as particularly useful when breast oedema affects the areola (Berens and Brodribb, 2016). The technique may also be useful when milk engorgement contributes to firm tissue around the nipple. Its purpose is to make the area around the nipple softer so that a baby can attach more easily and transfer milk effectively. It does not, however, remove milk from the breast or resolve every cause of breast fullness. The evidence for treatments for breast engorgement varies in quality. Cotterman (2004) described the rationale and technique for reverse pressure softening, while the Cochrane review of treatments for breast engorgement concluded that the evidence for many interventions was uncertain (Zakarija-Grkovic and Stewart, 2020). RPS is therefore a practical technique supported by clinical guidance, but it should not be presented as a treatment guaranteed to work in every situation. How to perform reverse pressure softening Reverse pressure softening is usually performed immediately before a breastfeed, when the area around the nipple feels firm, tight or swollen. It can also be used before hand expressing or using a breast pump if swelling around the nipple is making milk removal difficult. The technique should be gentle and comfortable. It is not a breast massage, and the intention is not to squeeze milk out of the breast. Step 1: Get comfortable Wash your hands and find a comfortable position. If your baby is ready to feed, keep them close so that you can offer the breast as soon as the tissue has softened. Step 2: Position your fingertips Place the pads of two or three fingers from each hand around the base of your nipple, positioning them in the area where your baby’s chin will rest against your breast in the feeding position you are about to use. Your fingers should be close to the nipple, rather than further away towards the outer breast. This helps you soften the area of the breast where your baby’s chin will make contact during feeding. Step 3: Apply gentle inward pressure Press the pads of your fingertips gently and steadily back towards your chest wall. The pressure should be directed inwards, rather than squeezing the nipple or pushing milk towards it. Keep the pressure comfortable. You should not need to use force, and the technique should not cause pain. Step 4: Hold the pressure Maintain the gentle inward pressure for around one to three minutes. Cotterman (2004) describes applying steady pressure to the subareolar tissue to reduce resistance and make the area more pliable. The aim is to temporarily soften the tissue around the nipple and areola. The amount of time required will vary according to the degree of swelling and how your breast responds. Step 5: Release and check the area Slowly release your fingers and gently check whether the area around your nipple feels softer. The areola may feel less taut and easier to compress between your fingers. If it remains very firm, repeat the technique gently. You do not need to continue until the whole breast feels soft; the immediate aim is to soften the tissue around the nipple sufficiently to help your baby attach. Step 6: Offer your baby the breast Offer the breast promptly while the area is softer. Support your baby in the feeding position you have chosen and allow them to open their mouth widely before bringing them towards the breast. Look and listen for signs of swallowing, and observe whether your baby is feeding actively and transferring milk. If your baby repeatedly slips off, cannot maintain attachment, or is not swallowing effectively, further support may be needed. You can read more about breastfeeding latch and positioning and recognising infant swallowing during feeds. Step 7: If your baby still cannot attach If the breast remains too firm for your baby to attach, gentle hand expression may remove a small amount of milk and soften the breast further. The intention is to make attachment easier and relieve uncomfortable fullness, rather than to repeatedly express large volumes in an attempt to empty the breast. If your baby cannot feed effectively, seek timely support to assess milk transfer and ensure that your baby is receiving enough milk. You may need an individual plan for feeding and expressing while the underlying difficulty is addressed. Guidance on how to express breast milk may also be helpful. Preventing engorgement Not all breast fullness can be prevented, particularly the normal changes that occur as milk production increases after birth. However, recognising difficulties early and getting appropriate support may help prevent engorgement from becoming more severe. Follow your baby’s feeding cues and seek support if feeding is difficult or feeds are repeatedly missed. Check that your baby can attach comfortably and transfer milk effectively. If your baby cannot attach because the areola is firm or swollen, try reverse pressure softening before the feed. If needed, hand express gently to soften the breast or provide milk for your baby, following an individual feeding plan. Avoid routinely expressing extra milk beyond what is needed, unless this is part of a plan to establish or maintain milk production. If you suspect oversupply, seek individual advice before making substantial changes to feeding or expressing. Seek support early if your breasts remain very full, feeding is painful, or your baby is not feeding effectively. An appropriately qualified infant-feeding professional, such as an International Board Certified Lactation Consultant (IBCLC), can help assess attachment, milk transfer, feeding frequency and any need for expressing. Further information about what an IBCLC is and how they support infant feeding is available in the Information Library. When to seek further support Reverse pressure softening is a practical technique to help with swelling around the nipple, but it should not be used as a substitute for assessment when symptoms are persistent or worsening. Seek prompt clinical advice if you develop a hot, red or increasingly painful area of the breast, fever, chills or flu-like symptoms. These can be signs of mastitis or another condition requiring assessment. Also seek feeding support promptly if your baby is unable to attach, is not swallowing effectively, is unusually sleepy at feeds, has fewer wet nappies than expected, or there are concerns about weight gain. Do not attempt to manage a worsening breast problem solely by repeatedly applying pressure, massaging firmly or expressing more and more milk. Management should be guided by the symptoms, the feeding situation and clinical advice where needed (Mitchell et al., 2022). References Berens, P. and Brodribb, W. (2016) ‘ABM Clinical Protocol #20: Engorgement, Revised 2016’, Breastfeeding Medicine, 11(4), pp. 159–163. Available at: https://doi.org/10.1089/bfm.2016.29008.pjb. Cotterman, K.J. (2004) ‘Reverse pressure softening: A simple tool to prepare areola for easier latching during engorgement’, Journal of Human Lactation, 20(2), pp. 227–237. Available at: https://doi.org/10.1177/0890334404264224. Johnson, H.M. et al. (2020) ‘ABM Clinical Protocol #32: Management of Hyperlactation’, Breastfeeding Medicine, 15(3), pp. 129–134. Available at: https://doi.org/10.1089/bfm.2019.29141.hmj. Kujawa-Myles, S., Noel-Weiss, J., Dunn, S., Peterson, W.E. and Cotterman, K.J. (2015) ‘Maternal intravenous fluids and postpartum breast changes: A pilot observational study’, International Breastfeeding Journal, 10, article 18. Available at: https://doi.org/10.1186/s13006-015-0043-8. Mitchell, K.B. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’, Breastfeeding Medicine, 17(5), pp. 360–376. Available at: https://doi.org/10.1089/bfm.2022.29207.kbm. Pang, W.W. and Hartmann, P.E. (2007) ‘Initiation of human lactation: Secretory differentiation and secretory activation’, Journal of Mammary Gland Biology and Neoplasia, 12(4), pp. 211–221. Available at: https://doi.org/10.1007/s10911-007-9054-4. Zakarija-Grkovic, I. and Stewart, F. (2020) ‘Treatments for breast engorgement during lactation’, Cochrane Database of Systematic Reviews, (9), CD006946. Available at: https://doi.org/10.1002/14651858.CD006946.pub4.

Jaundice is common in newborn babies, but it is important to understand that it has several possible causes. While many cases are temporary and resolve without treatment, some require prompt investigation and medical intervention. Feeding difficulties can contribute to certain types of jaundice. In some babies, restricted tongue movement associated with tongue-tie may be one factor affecting feeding effectiveness and milk transfer. However, tongue-tie does not directly cause jaundice, and jaundice should never be attributed to feeding difficulties without appropriate clinical assessment. This article explains the different types of infant jaundice, how feeding can be involved, and when families should seek medical advice. What is infant jaundice? Jaundice is the yellow appearance of the skin and the whites of the eyes caused by an increased concentration of bilirubin in the blood. Bilirubin is a yellow pigment produced when red blood cells are broken down. Newborn babies have a relatively high turnover of red blood cells, and their livers are still developing the ability to process and eliminate bilirubin efficiently. Bilirubin is processed by the liver and excreted primarily through the bowel. In newborns, this process can be slower, allowing bilirubin to accumulate temporarily (Maisels, 2015). Jaundice is common during the first days after birth. However, the appearance of jaundice alone cannot establish its cause or indicate how high the bilirubin level is. Bilirubin needs to be measured when clinically indicated, and the result interpreted in relation to the baby’s age in hours, gestational age and other risk factors (NICE, 2023). Types of infant jaundice The table below summarises some of the main types and causes of jaundice in newborn babies. These categories can overlap, and a baby may have more than one contributing factor. | Type of jaundice | Main cause or contributing factors | |---|---| | Physiological jaundice | Normal newborn red blood cell turnover combined with the liver’s developing ability to process bilirubin. | | Suboptimal intake hyperbilirubinaemia | Insufficient milk intake, which can reduce stool output and increase bilirubin reabsorption from the bowel. | | Breast milk jaundice | Persistent unconjugated hyperbilirubinaemia in some otherwise well babies receiving human milk, involving factors that affect bilirubin metabolism and elimination. | | Haemolytic jaundice | Increased breakdown of red blood cells, for example due to blood group incompatibility or certain inherited conditions. | | Jaundice associated with bruising or bleeding | Breakdown of blood collected in bruising, a cephalohaematoma or other bleeding. | | Jaundice associated with infection or systemic illness | Infection or other illness affecting bilirubin production, processing or elimination. | | Cholestatic jaundice | Impaired bile flow, which may be associated with liver or bile duct disease. This requires prompt investigation. | | Other medical causes | Conditions such as hypothyroidism or inherited metabolic disorders may cause or contribute to prolonged jaundice. | (NICE, 2023; Maisels, 2015; Flaherman and Maisels, 2017; Feldman and Sokol, 2021.) Physiological jaundice Physiological jaundice is the common, expected form of newborn jaundice. It usually becomes noticeable after the first 24 hours of life and is often most apparent around days three to five. It occurs because newborn babies produce bilirubin as red blood cells are broken down, while their liver’s capacity to process and eliminate bilirubin is still maturing. In many babies, the bilirubin level falls as their liver function develops and feeding becomes established. Although physiological jaundice is common, it should not automatically be assumed to be harmless. The bilirubin level may rise sufficiently to require treatment, and the timing, severity and progression of jaundice all matter. Jaundice appearing during the first 24 hours of life is particularly concerning and requires urgent medical assessment (NICE, 2023). Suboptimal intake hyperbilirubinaemia and “breastfeeding jaundice” Suboptimal intake hyperbilirubinaemia occurs when a baby does not receive enough milk. It often becomes apparent during the first few days after birth, particularly when feeding is not yet established. Insufficient milk intake can reduce the frequency and volume of bowel movements. As a result, bilirubin may remain in the bowel for longer and be reabsorbed into the bloodstream rather than being eliminated in the stool. This can contribute to rising bilirubin levels (Flaherman and Maisels, 2017). The term “breastfeeding jaundice” has traditionally been used to describe jaundice associated with inadequate milk intake during breastfeeding. However, this terminology can be misleading because it may suggest that breastfeeding itself causes jaundice. The relevant issue is whether the baby is receiving sufficient milk, not the feeding method alone. Babies receiving expressed human milk or formula can also develop jaundice if their intake is insufficient. Potential signs of feeding difficulties include: Feeding that is persistently ineffective or poorly coordinated. Difficulty maintaining sucking or becoming exhausted during feeds. Limited audible or visible swallowing. Feeding sessions that do not appear to result in effective milk transfer. Fewer wet or dirty nappies than expected for the baby’s age. Excessive weight loss or failure to gain weight as expected. Increasing sleepiness or difficulty sustaining feeds. These signs do not establish the cause of jaundice, and some babies with inadequate intake will not show every sign. Assessment should consider the baby’s clinical condition, bilirubin level, weight, hydration, output and feeding effectiveness. Breast milk jaundice Breast milk jaundice is distinct from jaundice associated with suboptimal milk intake. It describes persistent unconjugated hyperbilirubinaemia in some babies receiving human milk who are otherwise clinically well and feeding and growing adequately. It may continue for several weeks and, in some cases, for up to three months. Research has investigated components of human milk and their possible effects on bilirubin metabolism, but the mechanisms are complex and are not fully understood (Preer and Philipp, 2011; Gao et al., 2023). Breast milk jaundice should not be diagnosed simply because a baby is breastfed and remains yellow. Other causes of prolonged jaundice need to be considered, including conditions that affect the liver, bile flow or the breakdown of red blood cells. Breastfeeding can usually continue, but the baby needs appropriate assessment and monitoring. Families should not stop breastfeeding or change feeding plans without advice from the baby’s healthcare team. Haemolytic jaundice Haemolytic jaundice occurs when red blood cells break down more rapidly than usual, producing increased amounts of bilirubin. One possible cause is blood group incompatibility between the birthing parent and baby. Other causes include inherited red blood cell conditions, such as glucose-6-phosphate dehydrogenase (G6PD) deficiency. Haemolysis can cause bilirubin to rise quickly. Jaundice developing within the first 24 hours of life is a particularly important warning sign because it may indicate an underlying pathological cause. Urgent assessment and investigations are required to identify the cause and determine whether treatment is needed (NICE, 2023; Maisels, 2015). Jaundice associated with bruising or bleeding Babies may develop bruising during birth, and some develop a cephalohaematoma, which is a collection of blood beneath the scalp’s outer covering. As the collected blood breaks down, bilirubin is released, potentially increasing the bilirubin level. The presence of bruising does not rule out other causes of jaundice. The baby’s overall condition, bilirubin level and any other risk factors still need to be assessed. Jaundice associated with infection or other illness Infection and other medical conditions can affect bilirubin production, processing or elimination. Jaundice may occur alongside other signs of illness, although the signs are not always obvious at first. A baby with jaundice who is unwell, unusually sleepy, feeding poorly or showing changes in temperature or breathing requires urgent assessment. Jaundice should not be assumed to be physiological or feeding-related when a baby appears unwell. Conjugated hyperbilirubinaemia and cholestasis Not all jaundice is caused by unconjugated bilirubin. Conjugated hyperbilirubinaemia occurs when the level of conjugated bilirubin in the blood is raised. This can indicate a problem with the liver or the flow of bile, known as cholestasis. One important cause is biliary atresia, a rare condition in which the bile ducts are blocked or absent. Early recognition and specialist assessment are important because treatment outcomes can depend on timely diagnosis. Pale, chalky or cream-coloured stools and dark urine that stains the nappy are important warning signs. These findings should not be attributed to normal newborn jaundice or breast milk jaundice. They require prompt medical investigation (NICE, 2023; Feldman and Sokol, 2021). Prolonged jaundice Jaundice that continues beyond the expected period needs assessment, even if the baby otherwise appears well. NICE recommends further assessment when jaundice lasts more than 14 days in babies born at 37 weeks’ gestation or later, or more than 21 days in babies born before 37 weeks. Investigations may include measuring conjugated bilirubin and checking for other causes, according to the baby’s clinical circumstances (NICE, 2023). Breast milk jaundice is one possible explanation for prolonged jaundice, but it should not be assumed to be the cause before other important conditions have been considered. Can tongue-tie contribute to jaundice? Tongue-tie, also known as ankyloglossia, describes a restriction of tongue movement associated with the lingual frenulum. Its presence alone does not establish that a baby will have feeding difficulties. The functional impact varies between babies, and assessment should consider tongue movement alongside feeding function. In some babies, restricted tongue movement may contribute to difficulties achieving or maintaining an effective latch, generating suction, coordinating sucking and swallowing, or transferring milk efficiently. However, these difficulties can have multiple causes, and not every baby with tongue-tie experiences them. Where feeding is ineffective, milk intake may be insufficient. If this contributes to reduced stool output and increased bilirubin reabsorption, it may be one factor in the development of suboptimal intake hyperbilirubinaemia. This is an indirect and conditional relationship: tongue-tie does not directly cause jaundice, and jaundice should never be used on its own as evidence that a baby has tongue-tie. Feeding assessment should therefore consider the whole feeding picture, including milk transfer, swallowing, weight change, nappies, the baby’s alertness and the birthing parent’s experience where relevant. Evidence concerning frenotomy shows that outcomes are not uniform, reinforcing the importance of individual assessment and appropriate feeding support rather than assuming that every visible frenulum requires treatment (O’Shea et al., 2017; Knight et al., 2023). What can families do if their baby has jaundice and feeding difficulties? Medical assessment of jaundice is the priority. Feeding support is important, but it does not replace bilirubin measurement, investigation or treatment when these are indicated. Families who suspect jaundice should contact their midwife, health visitor, GP or neonatal team promptly for advice. The urgency depends on the baby’s age, symptoms and clinical condition. Jaundice in the first 24 hours of life requires urgent medical assessment. Where feeding difficulties are present, the healthcare team may recommend: Reviewing how often the baby feeds and whether they need to be woken for feeds. Observing a feed to assess sucking, swallowing and milk transfer. Monitoring the baby’s weight and wet and dirty nappies. Developing an individual feeding plan, including additional milk if clinically indicated. Arranging feeding support and follow-up to check that intake and the baby’s condition are improving. Waking a sleepy baby to feed may be part of an agreed feeding plan, but a baby who is unusually sleepy or difficult to wake needs urgent medical assessment rather than repeated attempts to feed at home. Effective swallowing and milk transfer are important considerations when assessing feeding. Families can read more about [swallowing and infant feeding here — insert link to the relevant Soro article]. Jaundice treatment may include phototherapy, and more intensive treatment may be necessary in severe cases. The decision depends on the measured bilirubin level and the baby’s age and risk factors. Families should follow the advice of their healthcare team and should not use sunlight as a treatment or give water to a newborn to try to reduce jaundice (NICE, 2023). When does jaundice need urgent assessment? Seek urgent medical advice if a baby develops jaundice after the first 24 hours of life, or if existing jaundice is worsening or not improving as expected. A baby with jaundice needs immediate medical assessment if they: Are difficult to wake, unusually sleepy or floppy. Are not feeding or cannot feed effectively. Have a high-pitched cry, abnormal stiffness, arching or unusual movements. Have a temperature of 38°C or above, or 36°C or below. Have no wet nappies or show signs of significant dehydration. Have difficulty breathing. Develop jaundice within the first 24 hours after birth. Pale, chalky stools or dark urine that stains the nappy also require prompt medical assessment. These may indicate a problem with bile flow rather than ordinary newborn jaundice. Jaundice can be harder to recognise visually in babies with darker skin. Families should not rely on the apparent depth of the yellow colour to judge severity, and healthcare professionals should not rely on visual inspection alone to estimate bilirubin levels (NICE, 2023; NHS, n.d.). If a baby with jaundice is difficult to wake, not feeding, floppy, having abnormal movements or experiencing breathing difficulties, seek emergency help. In the UK, call 999 or go to A&E in line with NHS advice. Supporting the whole feeding relationship Infant jaundice has several possible causes, and the correct response depends on identifying what is happening for the individual baby. Many babies experience temporary physiological jaundice, while others need treatment or investigation for an underlying condition. Feeding difficulties can contribute to suboptimal intake hyperbilirubinaemia, and a functional restriction of tongue movement may be one of several factors affecting milk transfer in some babies. However, neither tongue-tie nor breastfeeding should be treated as a default explanation for jaundice. The safest approach is timely medical assessment, appropriate monitoring and practical feeding support. Where tongue-tie is suspected, its functional impact should be assessed alongside other potential contributors to feeding difficulties. This allows the baby’s jaundice and feeding needs to be addressed without overlooking other important causes. References American Academy of Pediatrics (2022) ‘Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation’, Pediatrics, 150(3), e2022058859. Available at: https://doi.org/10.1542/peds.2022-058859. Feldman, A.G. and Sokol, R.J. (2021) ‘Neonatal cholestasis: updates on diagnostics, therapeutics, and prevention’, NeoReviews, 22(12), pp. e819–e836. Available at: https://doi.org/10.1542/neo.22-12-e819. Flaherman, V.J. and Maisels, M.J. (2017) ‘ABM clinical protocol #22: guidelines for management of jaundice in the breastfeeding infant 35 weeks or more of gestation—revised 2017’, Breastfeeding Medicine, 12(5), pp. 250–257. Available at: https://doi.org/10.1089/bfm.2017.29042.vjf. Gao, C., Guo, Y., Huang, M., He, J. and Qiu, X. (2023) ‘Breast milk constituents and the development of breast milk jaundice in neonates: a systematic review’, Nutrients, 15(10), 2261. Available at: https://doi.org/10.3390/nu15102261. Knight, M. 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. 1–73. Available at: https://doi.org/10.3310/WBBW2302. Maisels, M.J. (2015) ‘Managing the jaundiced newborn: a persistent challenge’, CMAJ, 187(5), pp. 335–343. Available at: https://doi.org/10.1503/cmaj.122117. National Institute for Health and Care Excellence (NICE) (2023) Jaundice in newborn babies under 28 days. Clinical guideline CG98. Available at: https://www.nice.org.uk/guidance/cg98. NHS (n.d.) Jaundice in babies. Available at: https://www.nhs.uk/conditions/jaundice-in-babies/. O’Shea, J.E. et al. (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. Preer, G.L. and Philipp, B.L. (2011) ‘Understanding and managing breast milk jaundice’, Archives of Disease in Childhood—Fetal and Neonatal Edition, 96(6), pp. F461–F466. Available at: https://doi.org/10.1136/adc.2010.184416.

Bifid uvula and tongue-tie A bifid uvula may be noticed during an examination of a baby’s mouth, sometimes alongside a suspected tongue-tie. These are different anatomical findings: a bifid uvula concerns the soft palate, while tongue-tie concerns the lingual frenulum beneath the tongue. The distinction matters because feeding difficulties can have more than one cause. A restrictive lingual frenulum may contribute to feeding difficulties in some babies, while a bifid uvula may be an isolated anatomical variation or a sign that the palate needs further assessment. Neither finding alone establishes the cause of a feeding problem or whether a procedure is appropriate (LeFort et al., 2021; Thomas et al., 2024). The oral structures should be considered together during the same assessment. If an anatomical variation is identified, its significance needs to be understood before proceeding with frenulotomy. Where a bifid uvula raises concern about a possible submucous cleft palate, appropriate specialist advice should be sought before tongue-tie division is considered. What is a bifid uvula? The uvula is the small, soft structure that hangs from the back of the soft palate. A bifid uvula is split, or appears forked, at its tip. The division may be subtle or more readily visible. A uvula may also have a notched appearance, where there is an indentation at its tip without a complete division. A bifid uvula is an anatomical variation, and its reported prevalence varies between populations. Feka et al. (2019) examined the prevalence of bifid uvula in primary school children in Geneva and reported a prevalence of 0.42% in their study population. Cambridge University Hospitals NHS Foundation Trust reports that around 2% of people have an isolated bifid uvula without other health concerns (Cambridge University Hospitals NHS Foundation Trust, 2023). These figures illustrate why prevalence estimates should be considered in the context of the population studied. An isolated bifid uvula does not automatically indicate a cleft palate or a functional problem. However, it can be a clinical sign of a submucous cleft palate, so the wider palatal examination and any associated symptoms are important (Feka et al., 2019; Reiter et al., 2011). A notched appearance should also be considered in the context of the whole examination rather than interpreted in isolation. The appearance of the uvula alone cannot establish whether the underlying palatal muscles are structurally or functionally affected. When might a cleft palate be present? A submucous cleft palate is a difference in the structure of the palate in which the mucosal covering may remain intact while the underlying palatal muscles have not developed or joined in the usual way. The palate can therefore look relatively normal despite differences in its structure and function (Calnan, 1954; Reiter et al., 2011). The traditional clinical signs associated with submucous cleft palate are: A bifid uvula. A translucent or bluish midline area in the soft palate, sometimes called zona pellucida. A notch at the back of the hard palate. These signs are often described as Calnan’s triad (Calnan, 1954). Not every individual with a submucous cleft palate has all three signs, and some cases can be difficult to identify from appearance alone (Reiter et al., 2011; ten Dam et al., 2013). This is why a bifid uvula should neither be treated as a diagnosis in itself nor dismissed without considering the wider clinical picture. An apparently intact palate does not necessarily exclude a submucous cleft. A specialist assessment may consider the shape and movement of the soft palate, the appearance of the hard palate, feeding history and any other features that suggest impaired palatal function. Further investigation may be indicated depending on the findings. For more information, see my article Submucosal cleft palate and feeding issues in infants. CLAPA also provides information about cleft lip and palate and NHS cleft services. Does an isolated bifid uvula affect feeding? An isolated bifid uvula would not usually be expected to cause feeding difficulties by itself. Cambridge University Hospitals NHS Foundation Trust explains that many babies with a bifid uvula have no other health concerns and feed well. The concern arises when the finding is associated with a submucous cleft palate or another difference affecting palatal function (Cambridge University Hospitals NHS Foundation Trust, 2023). The soft palate contributes to separating the mouth from the nasal cavity during swallowing. If the palate cannot close effectively, milk may pass into the nose during feeding. Other concerns can include prolonged feeds, tiring during feeds and difficulty maintaining effective feeding. These symptoms are not proof of a submucous cleft palate, but they warrant assessment when considered alongside the anatomical findings (Cambridge University Hospitals NHS Foundation Trust, 2023; Reiter et al., 2011). If a baby has a bifid uvula but is feeding comfortably, transferring milk effectively and growing as expected, this is reassuring. It does not, however, remove the need to follow the advice of the relevant cleft or paediatric team about whether monitoring or further assessment is appropriate. The key distinction is between the appearance of the uvula and the function of the palate. An isolated anatomical variation is not the same as a palate that cannot perform its usual role. Feeding difficulties associated with tongue-tie Tongue-tie, clinically termed ankyloglossia, concerns the lingual frenulum beneath the tongue. The frenulum is a normal anatomical structure, and its appearance varies considerably between babies. It becomes clinically relevant when restriction of tongue movement affects function (Messner et al., 2020; Thomas et al., 2024). Where tongue-tie is functionally significant, assessment may identify restricted tongue elevation or extension alongside feeding difficulties. During breastfeeding, these may include difficulty maintaining attachment, ineffective milk transfer or persistent nipple pain and trauma. With bottle feeding, the assessment may consider the baby’s seal around the teat, tongue and jaw movements, milk loss, feeding efficiency and coordination. These signs are not unique to tongue-tie. Clicking, prolonged feeds, milk leakage and unsettled behaviour can have several explanations. A visible frenulum or a single feeding symptom should not be used alone to diagnose a restrictive tongue-tie or determine whether frenulotomy is indicated (Messner et al., 2020; Thomas et al., 2024). The evidence base for frenulotomy has historically focused more heavily on breastfeeding outcomes, particularly maternal nipple pain, than on bottle-feeding outcomes. A Cochrane review found that frenotomy may reduce maternal nipple pain in the short term, but evidence for consistent improvement in infant feeding outcomes was limited by the quality and size of the included studies (O’Shea et al., 2017). Decisions about treatment therefore need to be based on an individual assessment rather than the presence of a frenulum alone. For more information, see: How is tongue-tie assessed in babies safely? Bottle feeding with a restriction Does my baby need a tongue-tie release? My article Infant Oral Anatomy: Structure, Function and Feeding explains how the tongue, palate, lips, cheeks and jaw work together during feeding, and why anatomy needs to be considered alongside function. Feeding difficulties associated with cleft palate Feeding difficulties associated with a submucous cleft palate have a different potential explanation from those associated with tongue-tie. Where palatal muscle function is affected, a baby may have difficulty achieving the separation between the mouth and nose needed for effective feeding. Possible signs include milk passing through the nose, tiring during feeds and prolonged feeds. The significance of these symptoms depends on the individual baby’s examination and overall feeding assessment. They should not automatically be attributed to tongue-tie simply because a lingual frenulum is visible (Cambridge University Hospitals NHS Foundation Trust, 2023; Reiter et al., 2011). Some babies with a cleft palate need specialist feeding equipment. Certain specialist bottles can help deliver milk when a baby cannot generate the suction required with a conventional bottle. These bottles may have soft, squeezable reservoirs or other features designed for particular feeding needs. The appropriate system and feeding technique should be demonstrated and advised upon by the specialist cleft team (Cambridge University Hospitals NHS Foundation Trust, 2023). These specialist bottles are used for particular feeding needs associated with cleft palate or palatal dysfunction. They are not required simply because a baby has an isolated bifid uvula, and they are not a treatment for tongue-tie. Families should not have to determine which equipment is appropriate without specialist advice. Where a baby has suspected or confirmed palatal dysfunction, the feeding plan should be developed with the relevant specialist team. This allows the baby’s anatomy, feeding ability, growth and wider needs to be considered together. When an anatomical variation changes the plan A bifid uvula identified during an oral assessment warrants consideration of the wider palatal anatomy, including whether a submucous cleft palate may be present. The tongue, lingual frenulum, palate and other oral structures should be considered together during the same assessment, rather than treating a suspected tongue-tie as an isolated finding. Where an anatomical variation is identified, its significance needs to be considered before proceeding with frenulotomy. If a submucous cleft palate is suspected, appropriate specialist advice should be sought and the potential implications for feeding and palatal function clarified before tongue-tie division is considered. This does not mean that a bifid uvula automatically rules out frenulotomy, or that a clinically significant tongue-tie cannot coexist with a palatal variation. The two findings can occur together. It means that the anatomical findings must be understood in context, and any concerns affecting the safety or appropriateness of the procedure need to be addressed first (Calnan, 1954; Reiter et al., 2011; Messner et al., 2020). The feeding assessment remains important throughout this process. Difficulties associated with restricted tongue movement and those associated with impaired palatal function may overlap, but they are not interchangeable. Identifying the structures involved helps guide appropriate feeding support, referral and decisions about whether frenulotomy is indicated. Who should families contact? If a bifid uvula or a notched uvula is identified, families can contact their GP or paediatric team to discuss assessment and referral. ENT services and specialist cleft teams can also advise about palatal differences. Families and clinicians do not need to be certain that a submucous cleft palate is present before asking for specialist guidance. If the clinician or family is unsure whether the finding is significant, contacting the local specialist cleft service to ask for advice is a reasonable next step. Specialist cleft teams across the UK assess palatal differences and can advise on the appropriate referral route (CLAPA, n.d.). If feeding is difficult, it is important to seek feeding support as well as investigating the anatomical finding. An IBCLC or other suitably qualified infant-feeding professional can assess feeding function and identify when referral to paediatric, ENT or cleft services may be appropriate. Where there is repeated milk regurgitation through the nose, significant feeding fatigue, faltering growth or other concerns about swallowing, timely clinical assessment is particularly important. Coughing, choking, colour changes or breathing difficulties during feeds also warrant prompt clinical attention. A baby with a bifid uvula who is feeding well may need a different plan from a baby who has feeding difficulties or other signs of palatal dysfunction. The appropriate pathway depends on the individual findings and advice from the relevant clinical team. References Calnan, J. (1954) ‘Submucous cleft palate’, British Journal of Plastic Surgery, 6(4), pp. 264–282. https://doi.org/10.1016/S0007-1226(53)80060-3 Cambridge University Hospitals NHS Foundation Trust (2023) Bifid uvula and submucous cleft palate. Patient information leaflet, approved 4 October 2023. Available at: https://www.cuh.nhs.uk/patient-information/bifid-uvula-and-submucous-cleft-palate/ CLAPA (n.d.) About NHS cleft services. Available at: https://clapa.com/what-is-cleft-lip-palate/about-nhs-cleft-services/ CLAPA (n.d.) What is cleft lip and palate? Available at: https://clapa.com/what-is-cleft-lip-palate/ Feka, P., Banon, J., Leuchter, I. and La Scala, G.C. (2019) ‘Prevalence of bifid uvula in primary school children’, International Journal of Pediatric Otorhinolaryngology, 116, pp. 88–91. https://doi.org/10.1016/j.ijporl.2018.10.026 Messner, A.H. et al. (2020) ‘Clinical Consensus Statement: Ankyloglossia in Children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. https://doi.org/10.1177/0194599820915457 O’Shea, J.E. et al. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. https://doi.org/10.1002/14651858.CD011065.pub2 Reiter, R., Brosch, S., Wefel, H., Schlömer, G. and Haase, S. (2011) ‘The submucous cleft palate: diagnosis and therapy’, International Journal of Pediatric Otorhinolaryngology, 75(1), pp. 85–88. https://doi.org/10.1016/j.ijporl.2010.10.015 ten Dam, E., van der Heijden, P., Korsten-Meijer, A.G.W., Goorhuis-Brouwer, S.M. and van der Laan, B.F.A.M. (2013) ‘Age of diagnosis and evaluation of consequences of submucous cleft palate’, International Journal of Pediatric Otorhinolaryngology, 77(6), pp. 1019–1024. https://doi.org/10.1016/j.ijporl.2013.03.036 Thomas, J. et al. (2024) ‘Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report’, Pediatrics, 154(2), e2024067605. https://doi.org/10.1542/peds.2024-067605

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

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

Tongue-tie assessment involves more than identifying a lingual frenulum or assigning a score to its appearance. The clinical question is whether the tongue’s structure and movement are restricted in a way that may affect feeding, and whether the findings are consistent with the difficulties experienced by the infant and feeding dyad. Several tools are used by healthcare professionals to assess infant tongue-tie, also known as ankyloglossia. They differ in their assessment criteria, the functions they examine and the evidence supporting their use. Some concentrate on anatomical appearance, some assess tongue movement, and others incorporate a broader range of oral function or feeding-related observations. Understanding these differences is important because a tool can help to structure an assessment without necessarily establishing the cause of feeding difficulties or predicting the outcome of frenulotomy. A score is one part of the clinical picture, not a substitute for clinical reasoning. The systematic review by Necus et al. (2025) identified nine assessment tools used in infants from birth to 12 months and found variation in their content and supporting evidence. This highlights the continuing challenge of identifying a consistent, reliable approach to assessing tongue-tie in infants. For further information, see What does a tongue-tie assessment consider? and How is tongue-tie assessed in babies safely?. The distinction between appearance and function The lingual frenulum is a normal anatomical structure. Its appearance varies between individuals, and visible differences do not automatically indicate a functional restriction. Conversely, the appearance of the frenulum alone may not fully describe how the tongue moves during feeding. Ankyloglossia is generally understood as a congenital condition in which the lingual frenulum restricts tongue movement. However, there is no universally accepted definition or single assessment method that establishes the clinical significance of every presentation (Messner et al., 2020; Thomas et al., 2024). A comprehensive assessment considers several related areas: Anatomy: the appearance of the lingual frenulum and its relationship to the tongue and floor of the mouth. Function: the tongue’s ability to elevate, extend, lateralise and move in ways relevant to feeding. Feeding impact: whether observed feeding difficulties are consistent with the functional findings, taking account of the wider feeding dyad. These areas need to be considered together. A visible frenulum, a particular attachment point or a numerical score cannot independently establish that tongue-tie is responsible for feeding difficulties. Hatami et al. (2022), in a systematic review of tongue-tie assessment tools, found limitations in the evidence supporting the use of assessment classifications to determine which infants would benefit from frenotomy. Identifying an anatomical variation, classifying its severity and deciding whether an intervention is clinically indicated are related but different tasks. Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF/ATLFF) The Hazelbaker Assessment Tool for Lingual Frenulum Function, also referred to as the Assessment Tool for Lingual Frenulum Function (ATLFF), was developed by Alison Hazelbaker. It assesses both the appearance of the lingual frenulum and aspects of tongue function. The tool includes anatomical features as well as functional items such as lateralisation, lift and extension of the tongue, alongside observations relating to sucking. Its broader structure is intended to provide more information than an assessment based on the frenulum’s appearance alone. Amir, James and Donath (2006) examined the reliability of the Hazelbaker tool. They reported good agreement between assessors for several functional items, although agreement was weaker for some appearance items. Their findings illustrate why the reliability of individual assessment components matters when interpreting a total score. The HATLFF/ATLFF has also been used as a comparison tool during the development of other assessment methods. However, its use as a reference does not establish that every tool correlated with it can independently predict feeding outcomes or the need for frenulotomy (Hatami et al., 2022). Bristol Tongue Assessment Tool (BTAT) The Bristol Tongue Assessment Tool was developed by Ingram et al. (2015) to provide a simpler, structured way of assessing tongue-tie in infants. The BTAT assesses four features: The appearance of the tongue tip. The attachment of the lingual frenulum to the lower gum ridge. Tongue elevation. Tongue protrusion. Each item contributes to the overall score, allowing the assessor to record findings consistently. Importantly, Ingram et al. (2015) state that the BTAT was developed from clinical practice with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function. The authors compared the BTAT with the ATLFF in a group of infant assessments and reported a strong correlation between the tools, alongside acceptable internal reliability and good consistency between assessors using the BTAT. These findings supported the BTAT as a practical, shorter assessment method. They do not demonstrate that a BTAT score alone can identify the cause of feeding difficulties or reliably predict which infants will benefit from frenulotomy. The 2026 systematic review and meta-analysis by Dhar et al. reported high discriminative accuracy for the BTAT and TABBY when identifying ankyloglossia. However, the authors rated the overall certainty of evidence as very low. The distinction between identifying a restrictive lingual frenulum and establishing its functional impact therefore remains important. Tongue-tie and Breastfed Babies Assessment Tool (TABBY) The Tongue-tie and Breastfed Babies Assessment Tool, known as TABBY, was developed by Ingram et al. (2019) as a pictorial version of the BTAT. TABBY uses illustrations to represent the same four assessment areas: tongue-tip appearance, frenulum attachment, elevation and protrusion. Its visual format is intended to make the assessment criteria easier to understand and apply consistently. The score ranges from 0 to 8, with lower scores indicating greater restriction according to the tool’s scoring system. The illustrations can help assessors communicate the features being observed, but the score still needs to be interpreted alongside the infant’s function and feeding assessment. Ingram et al. (2019) evaluated TABBY in clinical practice and reported high agreement between TABBY and BTAT scores. Agreement between two related tools is useful evidence of consistency, but it is not the same as demonstrating that either tool can predict feeding outcomes or the response to frenulotomy. The 2026 review by Dhar et al. considered BTAT and TABBY together and reported promising diagnostic discrimination, while emphasising the very low certainty of the overall evidence. These findings support structured assessment rather than using a score in isolation to determine treatment. Lingual Frenulum Protocol for Infants (LFPI) The Lingual Frenulum Protocol for Infants, developed by Martinelli and colleagues, provides a more comprehensive assessment framework. It incorporates a range of anatomical and functional observations and includes information relating to sucking and feeding. The original protocol was described by Martinelli, Marchesan and Berretin-Felix (2012). It has two parts: a clinical history, including questions about family history and breastfeeding, and a clinical examination incorporating anatomical and functional assessment alongside non-nutritive and nutritive sucking observations. Martinelli et al. (2016) subsequently published validation work on the protocol. Its broader scope is relevant when considering the relationship between oral structure, tongue movement and feeding function. Necus et al. (2025) identified the LFPI as the most comprehensive of the tools included in their review and reported that it had the greatest amount of reported reliability and validity evidence among the tools they examined. This should not be interpreted as proof that it is a definitive diagnostic standard. The review identified limitations in the evidence base across the available tools, and the comprehensiveness of a protocol does not automatically establish its ability to predict clinical outcomes. The LFPI illustrates the difference between a brief screening or classification tool and a more extensive assessment protocol. The appropriate approach depends on the clinical question, the assessor’s competence and the wider assessment of the infant and feeding dyad. Coryllos classification The Coryllos classification describes the anatomical location and pattern of lingual frenulum attachment. It divides tongue-tie into four types, from attachment at the tip of the tongue to attachment further underneath the tongue or towards its base. It is an anatomical classification rather than a numerical score of tongue function. The four types are commonly described as follows: Type I: the frenulum attaches at or very close to the tip of the tongue. The attachment may be associated with a heart-shaped appearance when the tongue is extended. Type II: the frenulum attaches approximately 2–4 mm behind the tongue tip, on or near the alveolar ridge. Type III: the frenulum attaches around the middle of the underside of the tongue and the middle of the floor of the mouth. Type IV: the frenulum attaches towards the base of the tongue and may be deep or submucosal, making it less readily visible on inspection. Types I and II are generally described as anterior presentations, while types III and IV are often discussed in relation to posterior tongue-tie. The term posterior tongue-tie is itself subject to debate, and the presence of a less visible frenulum does not independently establish functional restriction (Messner et al., 2020; Thomas et al., 2024). Unlike the BTAT or HATLFF/ATLFF, Coryllos classification does not assign points to several assessment items and produce a total score. The assessor assigns an anatomical type according to the attachment observed or palpated. The classification can therefore help describe the anatomical finding, but it does not measure the degree of restriction during feeding or establish whether the infant’s difficulties are caused by the frenulum. A type should not be interpreted as a direct measure of clinical severity or as an indication for frenulotomy. Kotlow classification The original Kotlow classification grades tongue-tie according to the measured length of the free portion of the tongue. This is the distance from the tongue tip to the point where the lingual frenulum attaches to the underside of the tongue. Kotlow (1999) proposed four classes based on this measurement, with shorter free-tongue length assigned a higher grade. The commonly reported original categories are: | Kotlow classification | Free tongue length | Description | |---|---:|---| | Within the stated normal range | More than 16 mm | Normal free-tongue length according to this classification | | Class I | 12–16 mm | Mild ankyloglossia | | Class II | 8–11 mm | Moderate ankyloglossia | | Class III | 3–7 mm | Severe ankyloglossia | | Class IV | Less than 3 mm | Complete ankyloglossia | These measurements describe the anatomical length of the free portion of the tongue. They do not directly measure the tongue’s ability to elevate, extend, lateralise or maintain the movements needed for effective feeding. It is important not to confuse Kotlow’s original length-based classification with modified grading systems that classify the position of the frenulum’s attachment in relation to the tongue tip. Modified systems may use different class boundaries and measurement criteria; the version being used should therefore be identified rather than treating all Kotlow grading systems as interchangeable. Obtaining a consistent measurement in an infant may also be challenging, particularly when tongue movement is restricted or the attachment point is difficult to identify. The classification should be understood as an anatomical description, not a comprehensive functional assessment. Kotlow’s original paper, ‘Ankyloglossia (tongue-tie): a diagnostic and treatment quandary’ (1999), proposed diagnostic criteria and a classification method. The use of a measurement to grade anatomy does not, by itself, establish whether frenulotomy is indicated or predict the likely feeding outcome. Comparing tongue-tie assessment tools | Tool | Main focus | Important consideration | |---|---|---| | HATLFF/ATLFF | Appearance and several aspects of tongue function, including sucking-related observations | A broader tool, but reliability varies between individual items | | BTAT | Four structured anatomical and movement items | Developed with reference to the ATLFF; a score does not independently establish feeding impact | | TABBY | Pictorial assessment of the same four areas as BTAT | Visual format may support consistent scoring; it does not replace clinical assessment | | LFPI | Broader anatomical and functional assessment, including sucking and feeding-related information | More comprehensive, although limitations remain in the evidence base | | Coryllos | Four types based on the location and characteristics of frenulum attachment | Describes anatomical type rather than providing a comprehensive functional score | | Kotlow | Original classification uses four grades based on measured free-tongue length | A measurement-based anatomical grade does not directly assess feeding function | The tools differ in purpose and scope, so they should not be treated as interchangeable. A tool designed primarily to classify anatomy answers a different question from a protocol that includes functional observations. Similarly, a tool’s reported reliability does not necessarily establish its validity for predicting feeding outcomes. Feeding assessment alongside tongue-tie assessment Tongue movement and feeding function need to be considered together. A structured tongue assessment can document anatomical features and movement, but it cannot replace an assessment of the feeding dyad. For breastfeeding, relevant observations may include attachment, positioning, milk transfer, sucking patterns, swallowing, maternal comfort and the sustainability of feeding. For bottle feeding, the assessment may also consider the infant’s oral seal, sucking pattern, coordination, flow tolerance and signs of feeding difficulty. The particular observations required depend on the infant and the reported concerns. The assessment also needs to consider other factors that may contribute to feeding difficulties. These can include positioning, feeding technique, milk flow, oral-motor function, infant state, discomfort and wider health or developmental considerations. The presence of a lingual frenulum does not establish that it is the cause of every feeding difficulty. An assessment should therefore explore the reported difficulties, observe feeding where appropriate and relate those findings to the tongue’s functional movement. This helps distinguish the identification of an anatomical variation from the clinical judgement that the variation is contributing to a feeding problem. Further reading includes What does an infant feeding specialist do?, What is an IBCLC? Feeding Support Explained and Lactation support: What does a Lactation Consultant do?. Training, competence and diagnostic responsibility Using an assessment tool consistently requires an understanding of its purpose, scoring criteria and limitations. Professionals also need to recognise when findings are unclear, when further assessment is needed and when feeding difficulties may have more than one contributing factor. Training can support consistent use of an assessment tool, but familiarity with a scoring system does not automatically establish competence in every aspect of tongue-tie assessment or frenulotomy. Practitioners need to work within their professional scope, training and governance arrangements, and should be familiar with the evidence and guidance relevant to their clinical role. The terms and conditions associated with individual tools may also differ. Professionals should check the relevant publication, permissions and training requirements rather than assuming that every tool has the same conditions for reproduction or teaching. Where frenulotomy is being considered, the practitioner responsible for the procedure must reach an appropriate clinical decision based on their assessment, the infant’s presentation and the feeding concerns. A score should not be used as the sole justification for a procedure. For further information, see What 'Tongue-tie School' teaches healthcare professionals and Tongue-tie training for evidence-based care. Integrating assessment findings into clinical decisions The Academy of Breastfeeding Medicine (2021) describes ankyloglossia as a functional diagnosis and states that the presence of a sublingual frenulum alone is not an indication for frenotomy. The clinical decision needs to consider whether there is a functional restriction associated with breastfeeding difficulties and whether appropriate support has addressed potentially modifiable factors. The American Academy of Pediatrics clinical report by Thomas et al. (2024) similarly emphasises the importance of a comprehensive assessment of feeding difficulties and consideration of other causes before intervention. These recommendations reinforce the distinction between anatomical identification and a decision about treatment. Assessment tools can help professionals record findings, communicate with colleagues and monitor changes over time. Their value depends on using them for the purpose for which they were developed and interpreting their findings in context. A clinical decision should bring together the infant’s oral anatomy, tongue movement, observed feeding, the concerns described by the feeding dyad and the response to appropriate feeding support. Where the findings do not align, further assessment may be needed rather than allowing a numerical score to determine the outcome. For related information, see Does my baby need a tongue-tie release?, When feeding doesn't feel right: Looking beyond tongue-tie and Tongue-tie: understanding assessment, feeding, treatment and aftercare. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. doi: 10.1089/bfm.2021.29179.ylf. Amir, L.H., James, J.P. and Donath, S.M. (2006) ‘Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function’, International Breastfeeding Journal, 1, article 3. doi: 10.1186/1746-4358-1-3. Dhar, V. et al. (2026) ‘Diagnostic Assessment of Ankyloglossia and Association With Infant Feeding Challenges: A Systematic Review and Meta-Analysis—Part 1’, Pediatric Dentistry, 48(2), pp. 68E–82E. Hatami, A., Dreyer, C.W., Meade, M.J. and Kaur, S. (2022) ‘Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review’, Australian Dental Journal, 67(3), pp. 212–219. doi: 10.1111/adj.12921. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2015) ‘The development of a tongue assessment tool to assist with tongue-tie identification’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 100(4), pp. F344–F349. doi: 10.1136/archdischild-2014-307503. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2019) ‘The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY)’, International Breastfeeding Journal, 14, article 31. doi: 10.1186/s13006-019-0224-y. Kotlow, L.A. (1999) ‘Ankyloglossia (tongue-tie): a diagnostic and treatment quandary’, Quintessence International, 30(4), pp. 259–262. Martinelli, R.L.C., Marchesan, I.Q. and Berretin-Felix, G. (2012) ‘Lingual frenulum protocol with scores for infants’, International Journal of Orofacial Myology, 38(1), pp. 104–112. doi: 10.52010/ijom.2012.38.1.8. Martinelli, R.L.C., Marchesan, I.Q., Gusmão, R.J., Honório, H.M. and Berretin-Felix, G. (2016) ‘Validation of the Lingual Frenulum Protocol for Infants’, International Journal of Orofacial Myology, 42(1), pp. 5–13. doi: 10.52010/ijom.2016.42.1.1. Messner, A.H. et al. (2020) ‘Clinical consensus statement: Ankyloglossia in children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. doi: 10.1177/0194599820915457. Necus, E., Claessen, M., Hennessey, N. and Smart, S. (2025) ‘Assessment of tongue structure and function in infants for the diagnosis of ankyloglossia: A systematic review’, International Journal of Pediatric Otorhinolaryngology, 196, article 112485. doi: 10.1016/j.ijporl.2025.112485. Thomas, J. et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 154(2), article e2024067605. doi: 10.1542/peds.2024-067605.

Infant feeding involves coordinated movement throughout the body. Whether an infant feeds at the breast or from a bottle, effective feeding requires the tongue, jaw, lips, cheeks, head and neck to work together, alongside breathing, swallowing, postural stability and the ability to maintain a comfortable, regulated state. Feeding difficulties are not always explained by milk supply, feeding equipment or oral anatomy alone. Muscular tension, restricted movement, asymmetry and difficulties coordinating oral movements may also influence how an infant attaches, maintains a seal, generates suction and transfers milk. Body-based therapies are sometimes used alongside skilled infant-feeding support to address musculoskeletal restrictions and movement patterns that may contribute to feeding difficulties. These approaches include physiotherapy, osteopathy, cranial osteopathy, craniosacral therapy and chiropractic care. Orofacial myofunctional therapy is another related discipline, although it is generally more appropriate for older children and adults who can participate actively in instructed exercises. Understanding the relationship between oral function, muscular tension and infant movement helps families and practitioners consider which forms of assessment and support may be useful. Birth, movement and infant feeding Infants adapt to movement and positioning throughout pregnancy, birth and early development. Their feeding skills also develop as they gain experience coordinating sucking, swallowing and breathing. Some infants demonstrate a preference for turning their head to one side, difficulty maintaining a comfortable feeding position, asymmetrical jaw movement or differences in their ability to attach to each breast. Others may struggle to maintain a deep latch, sustain suction or coordinate their oral movements efficiently. These observations can have several contributing factors. An assessment of infant feeding therefore benefits from considering the feeding mechanism alongside the infant's movement, posture, oral function and the circumstances of the feeding dyad. A body-based assessment may identify restrictions or asymmetries that warrant attention. This can complement a detailed feeding assessment, which considers attachment, sucking, swallowing, milk transfer and feeding comfort. The Association of Tongue-tie Practitioners (ATP) discusses the relationship between manual therapy and infant feeding in its manual therapy and infant feeding guidance. Its infant-feeding support information also provides further context for families seeking feeding support. Tongue-tie and oral muscle function The tongue plays a central role in feeding. Its movement contributes to attachment, maintenance of a seal, suction generation, milk transfer and the coordination of swallowing. Effective tongue function depends on more than the appearance of the tongue or its ability to protrude. A lingual frenulum is a normal anatomical structure beneath the tongue. When its structure restricts tongue movement and is associated with functional difficulties, the condition is commonly described as tongue-tie, or ankyloglossia. Research into the lingual frenulum has demonstrated its close relationship with the connective tissues of the floor of the mouth. Mills et al. (2020) examined the histological structure of the frenulum and floor-of-mouth fascia, describing the frenulum as a fold involving fascia and overlying oral mucosa. The study also identified variation in fascial thickness and tissue composition. Martinelli et al. (2014) investigated the histological characteristics of altered lingual frenulum tissue in children undergoing frenulum surgery. A restrictive frenulum may limit the tongue's ability to elevate, extend or move efficiently during feeding. An infant may compensate by changing jaw movement, recruiting other oral muscles differently or adopting an alternative feeding pattern. These compensations may affect the wider mechanics of feeding. Research following frenotomy has examined changes in both breastfeeding function and oral muscle activity. Santos et al. (2023) assessed 20 infants before and seven days after lingual frenotomy. The researchers reported improvements in breastfeeding assessment categories, including positioning, latch and sucking, alongside a reduction in the measured electrical activity of the masseter muscle. This provides an example of research examining both feeding outcomes and the activity of muscles involved in feeding after division. A tongue-tie is a structural restriction. Osteopathy, chiropractic care, physiotherapy and craniosacral therapy do not divide or remove the frenulum. Where a restrictive frenulum has contributed to altered movement or muscular compensation, body-based therapy may be considered as part of support for residual tension and movement patterns. Assessment for tongue-tie and decisions about whether division is appropriate remain separate clinical considerations. Further information is available in Choosing Your Tongue-tie Practitioner and Tongue-tie Release in England: UK CQC Requirements. Information about exercises discussed following tongue-tie division is available in Tongue-tie Release Exercises. Muscular tension, fascia and whole-body movement Muscles do not work in isolation. They are surrounded and connected by connective tissues, including fascia, which relates to structures such as tendons, ligaments and other supporting tissues. These tissues help support movement, transmit forces and allow structures to glide in relation to one another. Fascial anatomy has been explored extensively by Thomas Myers in Anatomy Trains, which describes proposed myofascial continuities between different regions of the body (Myers, 2020). Systematic reviews have examined the anatomical basis of these connections. Wilke et al. (2016) reviewed anatomical evidence for proposed myofascial chains and found strong support for some chains, with varying levels of support for others. Krause et al. (2016) examined evidence for force transmission along myofascial chains and found evidence of tension transfer between some connected structures. These findings provide a framework for considering how movement and tension may relate across connected tissues. The anatomical relationships are relevant to manual and movement-based approaches that consider the body as an interconnected system. Connective tissue can also change following injury, inflammation, surgery and tissue healing. Collagen is an important component of connective tissue, and its organisation and composition contribute to tissue strength and mechanical behaviour. Martinelli et al. (2014) investigated collagen characteristics in altered lingual frenulum tissue, while Mills et al. (2020) examined the histological structure of the frenulum and floor-of-mouth fascia. The relevance to infant feeding is that oral tissues, muscles and connective tissues operate together. A restrictive oral structure may influence local movement, and an infant may develop compensatory patterns in response to restricted movement or discomfort. These changes can be considered alongside the movement of the jaw, head and neck when assessing feeding. A whole-body assessment considers these relationships rather than assuming that every feeding difficulty originates at the breast, bottle or tongue. The purpose is to identify movement patterns or restrictions that may be contributing to the individual infant's presentation and consider appropriate support. The jaw and feeding mechanics The mandible, or lower jaw, is the only freely movable bone of the facial skeleton. Its movement is important for attachment, jaw stability and the coordination of the tongue and other oral structures during feeding. At the breast, the infant needs to maintain an effective attachment while coordinating tongue and jaw movement to generate the pressure changes involved in milk transfer. Geddes et al. (2008) investigated tongue movement and intra-oral vacuum during breastfeeding, demonstrating the importance of oral movement and pressure generation in milk removal. Bottle-feeding also requires coordinated oral movement and suction, although the flow characteristics of the teat and the feeding position influence how the infant manages the feed. Restricted jaw movement, asymmetry or excessive muscular effort may affect the infant's ability to maintain a comfortable and effective feeding pattern. Some infants demonstrate differences in how widely they open their mouth, how their jaw moves during sucking or how consistently they maintain a seal. The relationship between the stomatognathic system and body posture has been discussed in the literature, including by Cuccia and Caradonna (2009). In infant feeding, it is useful to consider jaw movement alongside tongue function, head position and the infant's overall comfort rather than assessing these structures in isolation. Facial asymmetry may also be observed alongside differences in head position or movement. These observations need to be interpreted in the context of the infant's development and clinical presentation. Torticollis Torticollis describes a head position in which the head tilts to one side, often with the chin turned towards the opposite side. Congenital muscular torticollis can involve tightness or shortening of the sternocleidomastoid muscle, although head-position preferences may have other causes. An infant who finds it difficult to turn comfortably in one direction may struggle to achieve a consistent feeding position. This can affect attachment at one breast, positioning during bottle-feeding or the infant's ability to maintain a comfortable posture while feeding. Watson Genna (2015) described how muscular and craniofacial asymmetry associated with congenital torticollis may influence breastfeeding mechanics. Positioning adjustments and support for comfortable movement can help the feeding dyad, while paediatric physiotherapy can assess and manage torticollis. Families may be able to request an NHS paediatric physiotherapy referral through their GP. The appropriate pathway depends on local services and the infant's needs. Skull shape Infant skull shape can influence how the head rests against a surface and how comfortably an infant turns and positions their head. Positional plagiocephaly describes asymmetrical flattening of the skull, while brachycephaly describes a relatively broad, short head shape with flattening at the back. Skull shape, head-turning preferences and neck movement may be considered together when an infant presents with feeding difficulties or positional asymmetry. An assessment of skull shape does not, by itself, explain a feeding problem, but it may provide useful context when considered alongside movement and oral function. Further discussion is available in Infant Skull Shape and Infant Feeding. Advice about sleep positioning remains important. Infants should be placed on their backs for every sleep, on a firm, flat surface, following current safer-sleep guidance (BASIS, n.d.; The Lullaby Trust, n.d.). Families can find further information from BASIS and The Lullaby Trust. Any advice about awake-time positioning or movement should be consistent with safe-sleep recommendations. Osteopathy and cranial osteopathy Osteopathy is a regulated healthcare profession in the UK. Osteopaths use clinical assessment and manual approaches to consider movement, function and musculoskeletal presentation. Cranial osteopathy is an approach practised by some osteopaths that uses gentle manual contact to assess and work with movement and tension. In the context of infant feeding, an osteopath may consider the movement of the head, neck, jaw and associated soft tissues, as well as the infant's general comfort and posture. The intended focus may include musculoskeletal restrictions or compensatory patterns that could make positioning or oral movement more difficult. Osteopathy does not release a restrictive lingual frenulum. Where tongue-tie has contributed to restricted movement or compensatory tension, osteopathic care may be considered alongside appropriate tongue-tie assessment and infant-feeding support. Research has investigated osteopathic treatment alongside lactation care. Herzhaft-Le Roy, Xhignesse and Gaboury (2017) conducted a randomised controlled trial involving 97 mother–infant dyads with biomechanical sucking difficulties. The study found statistically and clinically significant differences in LATCH assessment scores between the group receiving osteopathic treatment alongside lactation consultations and the control group. It did not find a significant difference in nipple-pain scores between groups. Fons et al. (2025) reported a pilot randomised controlled trial involving 40 healthy, full-term breastfed newborns with feeding dysfunction. The study examined osteopathic manipulative treatment alongside lactation support and reported greater improvement in feeding assessment in the treatment group. Chen et al. (2026) reviewed the literature on osteopathic manipulative treatment for the breastfeeding dyad. Their scoping review identified 35 studies, including 19 with feeding-related outcomes. The authors concluded that preliminary evidence suggests osteopathic manipulative treatment may support feeding-related outcomes and identified a need for further interdisciplinary research. The General Osteopathic Council maintains the statutory register of osteopaths in the UK. Families can use its register search to check a practitioner's registration. Chiropractic care and gentle manual approaches Chiropractic is a regulated profession in the UK. Chiropractors assess and manage musculoskeletal presentations using approaches that may include manual techniques, movement advice and soft-tissue work. The approach used with an infant should be appropriate to the infant's age, presentation and needs. Where an infant has restricted movement, positional asymmetry or muscular tension, a chiropractor may assess the musculoskeletal contribution to the presentation. The relevance of this approach to feeding depends on the individual assessment and the way any intervention is delivered. Chiropractic care does not treat or divide a restrictive lingual frenulum. It may be considered as a complementary approach where musculoskeletal factors are also being addressed, alongside direct assessment of feeding and oral function. The General Chiropractic Council (GCC) is the statutory regulator for chiropractors in the UK. Families can find information about registration and professional standards through the GCC website. Physiotherapy Physiotherapy can be relevant when an infant has restricted neck movement, torticollis, asymmetrical movement, postural difficulties or other musculoskeletal concerns. Paediatric physiotherapists assess movement and function and may use positioning, handling, movement activities and other appropriate interventions to support development. Where a feeding difficulty occurs alongside torticollis or a clear movement asymmetry, physiotherapy may help address the movement component while an infant-feeding practitioner assesses attachment, sucking, swallowing and milk transfer. Families can ask about NHS paediatric physiotherapy services through local healthcare pathways. Some families may also choose to access private paediatric physiotherapy. The Health and Care Professions Council (HCPC) maintains the statutory register for physiotherapists in the UK. Registration can be checked through the HCPC website. Craniosacral therapy Craniosacral therapy is a hands-on approach that uses gentle contact and is practised by some therapists working with infants. Practitioners may focus on perceived restrictions or tension and the infant's comfort and movement. Families considering this approach in relation to feeding may wish to understand the practitioner's training, experience with infants and approach to working alongside other professionals. Craniosacral therapy is distinct from cranial osteopathy, which is practised by osteopaths registered with the General Osteopathic Council. The Craniosacral Therapy Association provides information about its profession and practitioners through its website. Myofunctional therapy Orofacial myofunctional therapy focuses on the function and coordination of the muscles of the mouth and face. Depending on the individual, work may address tongue posture, lip seal, oral movement, swallowing patterns and related functional habits. Most structured myofunctional programmes are designed for school-aged children, adolescents or adults who can understand instructions and actively practise exercises. They are therefore not generally a direct substitute for infant-feeding assessment or hands-on support for a young infant who cannot follow instructed exercises. For older children and adults, myofunctional therapy may be relevant where oral function, tongue posture or swallowing patterns need further assessment and support. Suitability depends on the presenting concern and the practitioner's clinical scope. The British Society of Myofunctional Therapy (BSMFT) provides information about orofacial myofunctional therapy and its practitioners through its website. What does the research say? Research on body-based approaches to infant feeding includes randomised controlled trials, observational studies and reviews. Some studies have reported improvements in feeding assessments when osteopathic treatment is provided alongside lactation support. Herzhaft-Le Roy et al. (2017) found improved LATCH scores in the group receiving osteopathic treatment alongside usual lactation consultations. Fons et al. (2025) also reported greater improvement in feeding assessment in the treatment group in a pilot randomised controlled trial. The 2026 scoping review by Chen et al. brings together published research on osteopathic manipulative treatment for the breastfeeding dyad. Research into tongue-tie and oral muscle function also helps explain why feeding can involve changes beyond the frenulum itself. Santos et al. (2023) reported improved breastfeeding assessment scores following frenotomy alongside a change in masseter muscle activity. Histological studies by Martinelli et al. (2014) and Mills et al. (2020) provide further information about the structure of the lingual frenulum and its relationship with floor-of-mouth tissues. Research on myofascial chains provides a basis for considering connections between muscles and connective tissues in different parts of the body. Wilke et al. (2016) reviewed anatomical evidence for proposed myofascial chains, while Krause et al. (2016) examined evidence for force transmission along connected structures. Together, these areas of research support continued investigation of the relationship between oral function, movement, connective tissue and feeding. They also provide a rationale for considering the infant's presentation as a whole, rather than assuming that every feeding difficulty has a single cause. Infant-feeding support Body-based therapy is most useful to consider within a wider assessment of the feeding dyad. A feeding assessment can examine attachment, oral function, sucking patterns, swallowing, milk transfer, feeding comfort and the practical circumstances of breast or bottle feeding. An infant-feeding specialist may help identify the feeding difficulties that need attention and coordinate support with other relevant professionals. More information is available in What Does an Infant Feeding Specialist Do?. An International Board Certified Lactation Consultant (IBCLC) has completed the relevant international certification process and can provide specialist lactation care. IBCLCs can assess breastfeeding and help families consider feeding strategies, positioning, milk transfer and other factors affecting the feeding dyad. Read more in What Is an IBCLC? Feeding Support Explained. Families can search for an IBCLC through the Lactation Consultants of Great Britain directory or find information about certification and the international registry through IBLCE. Further information about lactation support is available on the D-Restricted lactation page. For bottle-feeding families, the choice of bottle and teat, feeding position and pacing can also influence the feeding experience. Further information is available in Choosing Bottles and Teats and How to Pace Bottle Feeds: A Calm, Practical Guide. The appropriate combination of support depends on the infant's needs. Some families benefit from feeding advice alone; others may need assessment of oral function, musculoskeletal movement or both. UK practitioner registers and directories The following organisations provide information about professional registration or practitioner directories. Statutory regulators and professional associations have different roles, so checking a practitioner's status should include consideration of their registration, training, scope of practice and experience with infants. Physiotherapy: the Health and Care Professions Council (HCPC) maintains the statutory register for physiotherapists. Osteopathy and cranial osteopathy: the General Osteopathic Council (GOsC) maintains the statutory register for osteopaths. Cranial osteopathy is an approach practised by some registered osteopaths. Chiropractic: the General Chiropractic Council (GCC) regulates chiropractors in the UK. Craniosacral therapy: the Craniosacral Therapy Association provides information about the profession and its practitioners. Orofacial myofunctional therapy: the British Society of Myofunctional Therapy provides information about the profession and practitioners. Tongue-tie assessment and division: the Association of Tongue-tie Practitioners provides information about tongue-tie practice and professional standards. Its guidance can be considered alongside Choosing Your Tongue-tie Practitioner. In England, providers carrying out regulated activities must meet the relevant Care Quality Commission (CQC) requirements. Further information about tongue-tie release and the regulatory context is available in Tongue-tie Release in England: UK CQC Requirements. References BASIS (n.d.) Safer sleep information. Available at: https://www.basisonline.org.uk/ Chen, A.I. et al. (2026) ‘Osteopathic manipulative treatment for the breastfeeding dyad: a scoping review’, Journal of Human Lactation, 42(3), pp. 595–619. doi: 10.1177/08903344261430249. Cuccia, A. and Caradonna, C. (2009) ‘The relationship between the stomatognathic system and body posture’, Clinical Anatomy, 22(5), pp. 556–565. Fons, D. et al. (2025) ‘Osteopathic manipulative treatment for management of feeding dysfunction in breastfed newborns’, Journal of Osteopathic Medicine, 126(8), pp. 383–391. doi: 10.1515/jom-2024-0133. Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. doi: 10.1016/j.earlhumdev.2007.12.008. Herzhaft-Le Roy, J., Xhignesse, M. and Gaboury, I. (2017) ‘Efficacy of an osteopathic treatment coupled with lactation consultations for infants’ biomechanical sucking difficulties: a randomized controlled trial’, Journal of Human Lactation, 33(1), pp. 165–172. doi: 10.1177/0890334416679620. Krause, F., Wilke, J., Vogt, L. and Banzer, W. (2016) ‘Intermuscular force transmission along myofascial chains: a systematic review’, Journal of Anatomy, 228(6), pp. 910–918. doi: 10.1111/joa.12464. Martinelli, R.L.C., Marchesan, I.Q., Gusmão, R.J., Rodrigues, A.C. and Berretin-Felix, G. (2014) ‘Histological characteristics of altered human lingual frenulum’, International Journal of Pediatrics and Child Health, 2(1), pp. 5–9. doi: 10.12974/2311-8687.2014.02.01.2. Mills, N., Geddes, D.T., Amirapu, S. and Mirjalili, S.A. (2020) ‘Understanding the lingual frenulum: histological structure, tissue composition, and implications for tongue tie surgery’, International Journal of Otolaryngology, 2020, article 1820978. doi: 10.1155/2020/1820978. Myers, T.W. (2020) Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 4th edn. Elsevier. Santos, H.K.M.P. de S. et al. (2023) ‘Effects of lingual frenotomy on breastfeeding and electrical activity of the masseter and suprahyoid muscles’, CoDAS, 35(2), e20210262. doi: 10.1590/2317-1782/20232021262. The Lullaby Trust (n.d.) Safer sleep overview. Available at: https://www.lullabytrust.org.uk/baby-safety/safer-sleep-information/safer-sleep-overview/ Watson Genna, C. (2015) ‘Breastfeeding infants with congenital torticollis’, Journal of Human Lactation, 31(2), pp. 216–220. doi: 10.1177/0890334414568315. Wilke, J., Krause, F., Vogt, L. and Banzer, W. (2016) ‘What is evidence-based about myofascial chains: a systematic review’, Archives of Physical Medicine and Rehabilitation, 97(3), pp. 454–461. doi: 10.1016/j.apmr.2015.07.023.

Post-Procedure Tongue Function Exercises (tongue function exercises, disruptive wound management, active wound management) Now that you have began to research 'restrictive tongue tie' and its implications, you will undoubtedly have noticed the conversations surrounding 'exercises'. Now, this is a very controversial topic and highly emotive. The biggest problem lies in the lack of definition between the differences between 'Wound Massage', 'Tongue Lifts/Sweeps', 'Active or Disruptive Wound Management', whether the parent or the practitioner does this and who is accountable?, How long for? and What the benefits actually are?! - This is because it is poorly backed up by a robust medical evidence base. As you can see, the terms alone are confusing and "dress-up" the 'act' using calming and gentle wording, and yet this may be painful. Examples of DWM, stretches or AWM may include: actively breaking the wound open multiple times a day and rubbing it, lifting the tongue to 'stretch' the wound, or sweeping a finger on the underside of the tongue to re-open the wound to delay healing, thus preventing reformation. These are practices that I DO NOT advocate. The stages of wound healing tells us that interfering with the wound healing process may cause further complications. Thickening of the wound causing further restriction, bleeding, infection or pain causing a feeding aversion all spring to mind, and yet internationally this is common-place routine post procedural care. ATP Position Statements - Disruptive Wound Management (2022) (The above link is from the Association of Tongue-tie Practitioners UK). Body Therapy To clarify, Body therapies such as osteopathy, chiropractic, cranial-sacral, orofacial myofunctional and physiotherapy are all specialties that are regulated by councils and governing bodies and this is not the same as 'disruptive/active wound management'. They do not advocate touching an open wound. Wound management suggestions, unless they are dual trained in a relevant speciality, is out of their remit. In the same way that I would not dream of trying to diagnose torticollis, as its not my speciality. Even if I was to suspect it-I'd refer to the professional in that field. Body therapies are very useful at addressing the tensions in the whole body caused by a variety of factors (such as a traumatic birth, birth presentation, or a restrictive tongue-tie are just a few examples) all of which can all interfere with efficient, effective infant feeding and overall health and well being. Interestingly, the nerve endings from the frenulum finish in the toes. I have most definitely seen improvements in the infants I treat who have also had a body therapy to relax, have less wind/reflux, sleep better and improved efficiency in feeding-especially if the jaw is taught from a restrictive frenulum! Please also see this link: Manual Therapy and Infant Feeding - Association of Tongue-tie Practitioners How I can help I have also trained in the speciality of Orofacial techniques and the YTM tool method for infants which are relatively new concepts in the world of body-therapy. It specifically looks at the tongue and surrounding oral muscles and structures and links how these can impact on other bodily function such as eating, drinking, breathing and sleeping. At your tongue-tie consultation with me, I will give you specific gentle exercises to help assist your little one in reducing any tension of the face and tongue strengthening exercises too. These are optional of course but will give your little one a 'head-start' to effective feeding. Ultimately, your chosen provider is accountable for their suggestions and actions so please do refer to that practitioner and follow their advice. This blog is my opinion only and is aimed for the families of the infant's I treat. As always, please feel free to contact me with any questions or queries that you may have at: diana@tongue-tie.info © Diana Warren IBCLC, RGN D-Restricted Ltd

The exaggerated latch technique, sometimes called the flipple or flipple nipple technique, is an approach to breastfeeding attachment that aims to help a baby take a deeper, more asymmetrical mouthful of breast tissue. It may be particularly useful for some babies with a high palate, where the shape of the roof of the mouth can influence how the nipple and breast tissue fit within the oral cavity. The technique involves applying gentle pressure near the base of the nipple to angle it upwards towards the baby's forehead, in line with the nose. As the baby opens their mouth and extends their head backwards, they are brought close to the breast, chin first. The pressure is then released as the baby attaches, allowing them to draw the nipple and breast tissue further into the mouth through their own feeding movements and suction (La Leche League GB, 2026). Understanding the anatomy of the palate, the importance of head extension and the mechanics of attachment helps explain why this technique may be useful for some babies with a high palate. Understanding the palate and breastfeeding The palate forms the roof of the mouth and the floor of the nasal cavity. It consists of two anatomically distinct regions: the hard palate at the front, which is supported by bone, and the soft palate towards the back, which contains muscle and movable soft tissue (Standring, 2021). Palates naturally vary in shape, width and height. A high palate has a more pronounced upward arch than a lower, more gently curved palate. This anatomical variation does not automatically indicate a feeding difficulty, but it can influence the space available for the tongue and the relationship between the nipple, breast tissue and other oral structures during feeding. During breastfeeding, the baby draws the nipple and breast tissue further into the mouth as attachment develops. With a deep, asymmetrical latch, the nipple is positioned towards the junction of the hard and soft palates rather than being compressed against the front of the hard palate. La Leche League GB and NHS guidance both describe the importance of a generous mouthful of breast tissue and allowing the baby's head to tip backwards so the nipple can reach further into the mouth (La Leche League GB, 2026; NHS, 2026). Head extension is particularly important because it allows the baby to open their mouth widely and approach the breast at an angle that supports deeper attachment. The chin can make contact with the breast first while the nipple enters the upper part of the mouth (NHS, 2026). For some babies with a high palate, the shape of the oral cavity may influence how the nipple and breast tissue sit within the mouth. Depending on the baby's anatomy and oral function, this may contribute to nipple compression, difficulty maintaining a seal or repeated loss of attachment. These effects are not inevitable, however, and a high palate should be considered alongside the baby's tongue movement, jaw movement, oral coordination and feeding behaviour. For further information about the structures of the mouth and their relationship with feeding, see Infant Oral Anatomy: Structure, Function and Feeding. How the exaggerated latch technique works La Leche League GB describes the flipple as an optional technique for encouraging deeper attachment. Gentle pressure is applied near the base of the nipple to tilt it away from the baby. As the baby opens widely, the breast is brought close so that the nipple enters the mouth last and rolls into position (La Leche League GB, 2026). The direction of the nipple is important, but the technique is not simply about pointing the nipple upwards. The baby's head needs to be free to extend backwards as the mouth opens, allowing the chin to approach the breast first. Head extension, the angle of the nipple and the timing of the caregiver's hand movements work together. The position of the thumb or finger varies according to the feeding position. In many positions, pressure is applied from the upper surface of the breast, viewed from above, with the thumb near the base of the nipple. The nipple is angled upwards towards the baby's forehead, in line with the nose. This should not be interpreted as a fixed instruction to press from underneath the breast; the hand may need to approach from a different direction when the baby's position changes. As the baby opens widely and comes onto the breast, the initial pressure is released. The baby's own mouth movements and suction then help draw the nipple and surrounding breast tissue further into the mouth. Research using ultrasound and measurements of intra-oral vacuum has demonstrated the relationship between tongue movement, vacuum generation and milk flow during breastfeeding (Geddes et al., 2008). The intention of the exaggerated latch technique is for the breast tissue to occupy more of the oral space, including the contour of the palate, while the nipple sits further back rather than remaining compressed towards the front of the hard palate. Once the baby is securely attached and rhythmic swallowing can be seen, the mother can remove her hand from the breast and allow her arm to relax into a more comfortable position, provided the breast and baby remain well supported. Maintaining the same hand position throughout the feed is not the objective; the aim is to facilitate attachment and then allow the baby to feed effectively without unnecessary effort from the mother. The technique builds on the wider principles of deep, asymmetrical attachment described in NHS guidance and breastfeeding support resources. Although the underlying principles of positioning and attachment are established, research specifically evaluating the flipple as a named technique, particularly for babies with a high palate, remains limited. For further explanation of the relationship between body position, head movement and attachment, see Breastfeeding latch and positioning. Why might the flipple help a baby with a high palate? With a high palate, the shape of the roof of the mouth may influence how the nipple and breast tissue fit within the oral cavity. The direction in which the nipple enters the mouth can therefore be particularly relevant. By changing the starting angle of the nipple, the exaggerated latch encourages the baby to take the breast into the mouth with the nipple directed upwards towards the forehead. As the baby extends their head, opens widely and approaches chin-first, the nipple can enter the mouth further back. Releasing the thumb pressure as the baby attaches allows their own suction to draw the breast tissue further into the oral cavity. The intended effect is for the breast tissue to fill more of the space within the mouth, accommodating the contour of the palate while the nipple sits further back. This may help some babies maintain a wider jaw position and reduce compression of the nipple against the hard palate towards the front of the mouth. The potential benefit is therefore not simply that the baby takes a larger mouthful of breast. It is also about the relationship between the nipple, breast tissue, palate and jaw once the baby has attached. This is a proposed mechanical explanation for why the technique may help some babies with a high palate, rather than a clinically established, palate-specific treatment. Its usefulness depends on the individual baby's anatomy, oral movement and ability to sustain effective feeding. The tongue also plays an important role in maintaining the seal around the breast and coordinating sucking and swallowing. Research by Geddes and colleagues (2008) demonstrated that milk flow during breastfeeding coincided with lowering of the posterior tongue and increased intra-oral vacuum. Genna et al. (2021) also explored tongue movement during infant feeding and adult swallowing, examining patterns of tongue kinematics. These studies help explain the complexity of oral movement during feeding, but neither establishes that the flipple improves vacuum or swallowing in babies with a high palate. Where tongue movement is restricted or oral coordination is affected, changing the angle of attachment may not address every contributing factor. Clicking, repeated loss of attachment and nipple compression can have several explanations, so these observations need to be considered within the wider feeding assessment rather than attributed automatically to palate shape. For further reading, see Infant Resting Tongue Posture: Why It Matters and What It Can Tell Us and Why Does My Baby Click When Feeding? Understanding the Causes. How to use the exaggerated latch technique The following steps describe the practical application of the technique. The position of the thumb or finger may need to change according to the feeding position, breast shape and direction from which the baby approaches the breast. 1. Find a comfortable feeding position Choose a position in which you are well supported and your baby can come close to the breast without stretching or twisting. The baby's nose should initially be approximately level with the nipple, allowing space for the head to extend backwards as the mouth opens. Support the baby's shoulders, neck and upper back so that their head can move freely. Avoid pushing the back of the head towards the breast, as this can restrict the extension needed for a wide gape and comfortable attachment (NHS, 2026). The technique can be adapted to different positions, provided the baby can extend their head, approach the breast comfortably and attach effectively. 2. Angle the nipple towards the forehead Place your thumb or finger near the base of the nipple, where the nipple meets the breast, and apply gentle pressure to angle the nipple upwards towards the baby's forehead, in line with their nose. The position of your hand depends on the feeding position. In many cases, the thumb rests on the upper surface of the breast when viewed from above, but another position may require a different hand placement to achieve the same angle. The aim is to change the direction in which the nipple is presented, rather than compressing the nipple or pressing the breast painfully. 3. Allow head extension and wait for a wide gape With your baby positioned nose-to-nipple, allow the nipple to brush the upper lip or the area around the nose. This can encourage the baby to open their mouth in preparation for attachment. As the baby responds, allow their head to tip backwards into extension. This is crucial to the technique. Head extension helps the baby open their mouth widely and changes the angle at which the nipple enters the mouth. Wait for the mouth to open widely enough to take a generous mouthful of breast tissue. The baby should be able to move their head freely rather than having their mouth forced open or their head held in place. 4. Bring the baby to the breast, chin first As the baby opens widely and their head extends backwards, bring them close to the breast so that the chin makes contact first. Keep the nipple angled upwards towards the forehead rather than pointing directly forwards into the centre of the mouth. As the baby attaches, release the thumb or finger pressure. The baby can then draw the nipple and breast tissue further into the mouth through their own feeding movements and suction. The nipple can roll further into the mouth as the baby closes around the breast, allowing more breast tissue to be taken in rather than the baby attaching primarily to the nipple. 5. Check the latch, and look for effective, rhythmical and PAIN FREE swallowing Once the baby is attached, observe how the feeding feels and functions rather than judging the latch by appearance alone. The baby's chin will generally remain close to the breast, with the nose sufficiently clear for comfortable breathing. More of the darker skin around the nipple may be visible above the upper lip than below the lower lip, reflecting an asymmetrical attachment, although the appearance varies with individual anatomy (NHS, 2026). Look for rhythmic sucking and swallowing, and consider whether the mother is comfortable without persistent pinching or sharp pain. Once the baby is securely attached and rhythmic swallowing is visible, the mother can remove her hand from the breast and relax her arm into a more comfortable position, as long as the baby remains supported and attachment is maintained. If the latch remains uncomfortable or the baby repeatedly slips off, gently release the suction before trying again. If the technique does not improve comfort or attachment, the wider feeding picture needs to be considered. For additional guidance on latch mechanics and positioning, see How to Improve Infant Latch: Practical Breastfeeding Support. Other avenues to explore Breastfeeding is multifactorial. Positioning and attachment are important, but the feeding experience is also influenced by the baby's oral function, breast and nipple anatomy, milk flow, breast fullness, the baby's state and development, and the coordination of sucking, swallowing and breathing (NICE, 2021; Watson Genna, 2023). The exaggerated latch may be useful when the angle of attachment appears to be contributing to nipple compression or difficulty maintaining a deep latch. However, persistent pain, repeated loss of attachment or concerns about milk transfer warrant a broader assessment rather than repeated attempts to perfect the same technique. An assessment may consider the baby's tongue movement, jaw movement and ability to maintain a seal around the breast; whether the baby can coordinate sucking and swallowing and sustain effective feeding; the caregiver's breast and nipple anatomy, comfort, milk production and milk flow; and whether the feeding position allows the baby to approach the breast and maintain attachment comfortably. Tongue-tie may be one consideration when restricted tongue movement appears to affect feeding function, but the appearance of the frenulum alone does not establish the cause of feeding difficulties. Equally, not every baby with a high palate has a feeding problem, and not every baby who struggles to attach has a high palate or tongue-tie. An IBCLC or another appropriately qualified healthcare professional with infant feeding expertise can observe a feed and help determine which factors may be contributing. Persistent nipple pain should not simply be accepted as part of breastfeeding; the Academy of Breastfeeding Medicine recommends a careful history and assessment of the feeding dyad when pain continues, rather than assuming that one explanation applies to everyone (Berens et al., 2016). Tongue movement and coordination contribute to the baby's ability to maintain an effective seal, generate intra-oral vacuum and coordinate sucking and swallowing. Where these functions are affected, positioning and attachment techniques may not address every contributing factor. You may find it helpful to read Tongue Function Exercises for Strength, Tone and Motility, which explores exercises to support tongue function, and Tongue-Tie Release Exercises, which discusses exercises following tongue-tie division and the distinction between functional exercises and wound manipulation. You may also find the following articles useful when exploring other possible contributors: Breastfeeding latch and positioning discusses the relationship between positioning, head movement and attachment. Breastfeeding latch support that helps explores persistent nipple pain and the importance of assessing the whole feeding dyad. A guide to understanding your baby's oral function considers oral movement and feeding function without relying on anatomy alone. Infant Skull Shape and Infant Feeding explores how positioning and the wider feeding mechanism may be relevant when an individual baby experiences difficulties. References Berens, P., Eglash, A., Malloy, M. and Stuebe, A.M. (2016) ‘ABM Clinical Protocol #26: Persistent pain with breastfeeding’, Breastfeeding Medicine, 11(2), pp. 46–53. doi: 10.1089/bfm.2016.29002.pjb. Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. doi: 10.1016/j.earlhumdev.2007.12.008. Genna, C.W. (ed.) (2023) Supporting Sucking Skills in Breastfeeding Infants. 4th edn. Burlington, MA: Jones & Bartlett Learning. Genna, C., Saperstein, Y., Siegel, S., Laine, A. and Elad, D. (2021) ‘Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns’, Physiological Reports, 9(3), e14685. doi: 10.14814/phy2.14685. La Leche League GB (2026) Positioning & Attachment. Updated May 2026. Available at: https://laleche.org.uk/positioning-attachment/ National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194 NHS (2026) Breastfeeding: positioning and attachment. Page last reviewed 23 June 2026. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/positioning-and-attachment/ Standring, S. (ed.) (2021) Gray's Anatomy: The Anatomical Basis of Clinical Practice. 42nd edn. London: Elsevier.

Choosing a bottle can seem surprisingly complicated. Walk into a shop or search online and you will find bottles described as anti-colic, breast-like, natural, physiological, orthodontic, wide-neck, slow-flow, variable-flow and more. Teats come in different shapes, lengths, widths, materials and flow rates, and some bottles contain valves or several separate components. It can be difficult to work out what actually matters and what is simply clever packaging. There is no single bottle or teat that is right for every baby. The NHS also states that there is no evidence that one type of bottle or teat is better than another, and suggests that simple bottles which are easy to wash and sterilise are probably best (NHS, 2026a). At the same time, research does show that the characteristics of a bottle and teat can influence how milk flows and how a baby sucks, swallows and breathes. The important distinction is that this does not mean one particular brand or design is universally better. Your baby's mouth, palate, oral movements, sucking skills, milk flow, feeding position and overall coordination all contribute to how a particular teat works for them. Teat shape matters Teats are not all shaped in the same way. Some are relatively short and flat, some are rounded, some are long and narrow, and others have a broad base which gradually tapers towards the end. The shape changes the way the teat sits inside the baby's mouth and the way the lips, tongue and jaw can interact with it. Bottle feeding is not simply a matter of milk dripping through a hole. Babies use a combination of suction and compression to remove milk, and the characteristics of the teat can influence how that happens (Kotowski et al., 2020). A short, relatively flat teat may encourage more compression of the teat between the tongue and palate or gums. A broader, gradually tapered teat provides a different structure for the mouth to work around. This does not mean that one shape will automatically produce a better feed, or that a particular teat will suit every baby. I generally favour a broad, gradually tapered or sloping teat, particularly when a family is combination feeding. There is some research suggesting that teat design can influence oral movements and sucking patterns. For example, Segami et al. (2013) studied an experimental teat with a wide base and firm shaft and found similarities in some perioral movements and sucking patterns when compared with breastfeeding. However, this was a small study involving an experimental teat, so it cannot be used to conclude that every broad teat is more physiological or better for breastfeeding. This distinction is important because bottle manufacturers increasingly use terms such as "breast-like" or "designed to mimic breastfeeding". A 2025 study of bottles marketed in the UK found that claims about mimicking breastfeeding physiology, supporting combination feeding, reducing bottle refusal or preventing nipple confusion were common, but the scientific evidence underpinning those marketing claims was scarce and often inadequate (Maxwell, Self and Bould, 2025). A broad, gradually tapered teat may therefore be a practical choice for some babies, particularly alongside responsive or paced bottle feeding, but it cannot guarantee that a baby will continue to move comfortably between breast and bottle. It is also worth remembering that compression and suction are not the same thing. Babies can use both during bottle feeding, and the balance between them can vary according to the teat, flow and the individual baby's oral movements. A baby using more compression is not necessarily "doing it wrong", but if the feeding pattern is inefficient, tiring or uncomfortable, it is worth looking at the whole feeding picture rather than simply changing the bottle. You don't have to stay loyal to one teat brand Babies change as they grow, and the teat that works well at one stage may not always be the one that works best later on. Their mouth grows, their oral skills develop, their sucking becomes more coordinated and their feeding needs can change. A teat that was comfortable and effective when a baby was younger may eventually feel too slow, too fast, too short or simply different from what they now manage comfortably. This is one reason I would be cautious about becoming too attached to a particular brand or assuming that moving up within the same range is always the answer. Different manufacturers use different shapes, materials, flow rates and age recommendations, so a "next stage" teat from one brand may behave quite differently from another brand's equivalent. Watching how your baby is actually feeding is more useful than relying on the number or age printed on the packet. The same applies if you are combination feeding. A teat that worked alongside breastfeeding in the early weeks may not necessarily remain the best option as your baby's feeding skills develop. Equally, changing a teat is not something that needs to happen simply because a manufacturer suggests a particular age. If your baby is feeding comfortably, maintaining a good suck-swallow-breathe pattern and managing the flow without difficulty, there may be no reason to change it simply because the packaging says they have reached the next stage. Sometimes, however, a change can be helpful. Your baby's developing oral anatomy, palate shape, sucking skills, milk flow needs or overall feeding pattern may all influence which teat works comfortably for them. This is where looking at the whole feeding picture becomes more useful than choosing a teat based on brand loyalty alone. Your baby's palate can make a difference The roof of the mouth provides part of the surface against which the tongue works during feeding, so palate shape can influence how a teat sits and how the tongue and jaw interact with it. A high or narrow palate does not automatically mean that a baby will struggle with bottle feeding, and there is no single teat designed for every baby with a particular palate shape. However, if a teat repeatedly slips, is difficult for the baby to maintain in the mouth, or feeding involves considerable compression, dribbling or fatigue, the shape and dimensions of the teat may be worth considering alongside other aspects of the feed. There is some evidence that oral cavity dimensions and teat dimensions are relevant to sucking performance, although much of the research is older and does not provide a simple prescription for which teat should be used (Hummel and Herrmann, 1989). A case report has also described a newborn with a high arched palate whose feeding improved when a larger-hole teat was used, although a single case cannot be used to establish a general recommendation (Eren, Bilgin and Kara, 2015). This is a good example of why a teat should not be selected solely because it is marketed for a particular oral shape. The individual baby's response matters more than the label. Premature babies may have different needs Premature and very-low-birth-weight babies may have different feeding requirements because their sucking, swallowing and breathing coordination is still developing. Teat choice can therefore become part of a more individualised feeding assessment. Research in very-low-birth-weight infants has shown that different bottle nipples can affect sucking and milk transfer (da Costa, van den Engel-Hoek and Bos, 2008). This does not mean that there is one particular "premature baby teat" that is best for every baby. The appropriate equipment may depend on gestational age, oral size, feeding maturity, respiratory status and the baby's ability to manage the flow. For a premature baby, particularly one who is still developing coordinated oral feeding, bottle and teat selection is best considered alongside the wider feeding assessment rather than by age or packaging alone. Teat flow is not standardised One of the most confusing things about bottle feeding is that a "slow", "medium" or "fast" teat does not have a universal meaning. Manufacturers use their own terminology and their own testing methods. A slow-flow teat from one company can therefore behave very differently from a slow-flow teat from another. This has been demonstrated in research. Pados, Park and Dodrill (2019) measured 375 individual nipples representing 25 different types and found milk flow rates ranging from 0.86 to 37.61 mL per minute. The information printed on the packaging did not accurately reflect the measured flow rates. The physical characteristics of the teat also matter. Material, shape, hole size, rigidity and compressibility can all affect milk flow, alongside how much pressure the individual baby generates (Kotowski et al., 2020). This is why the age printed on a packet should not be treated as a developmental requirement. It is manufacturer guidance. The NHS similarly advises that as babies become used to bottle feeding and grow, changes in flow can be considered, but this should be led by the baby rather than a rigid age rule (NHS, 2026b). Faster is not necessarily better It can be tempting to think that a baby who is getting older should automatically move to a faster teat. Sometimes a faster flow is appropriate, but faster is not inherently better. A flow that is too fast for an individual baby can make it harder to coordinate sucking, swallowing and breathing. You might notice coughing, spluttering, gulping, milk leaking from the mouth, pulling away from the bottle or becoming unsettled during the feed. A flow that is too slow can also be difficult. Some babies may suck for a very long time, become tired or frustrated, or fall asleep before taking enough milk. Research has demonstrated that babies can adapt their sucking patterns to different teat flows. Lagarde et al. (2019), for example, found differences in swallow rate and suck-to-swallow ratios when healthy infants used teats with different flow characteristics. The study was small, involving 16 term-born infants aged two to five months, and one of the teats had a higher measured flow than the other. The aim is therefore not to find the fastest flow a baby can tolerate. It is to find a flow that allows that particular baby to feed comfortably and coordinate their sucking, swallowing and breathing. What about variable-flow teats? Variable-flow or vari-flow teats allow the milk flow to change according to how the teat is positioned or how the baby sucks. They can be useful in some circumstances, but I am cautious about them for babies who already have difficulty with oral-motor coordination. For a baby who has tongue restriction or other difficulty coordinating their sucking pattern, a flow that changes according to pressure or positioning can sometimes make the feeding experience less predictable. That does not mean that variable-flow teats are unsuitable for every baby with a tongue-tie, but they are not a choice I would make automatically. If a baby is already struggling to control milk flow, it can be useful to simplify the variables and consider whether a consistent, predictable flow would make feeding easier to assess. What does the valve actually do? Many bottles contain a valve or venting system. The basic mechanical purpose is quite simple: as milk leaves the bottle, air needs to enter the bottle to replace the lost volume. Without adequate venting, a vacuum can develop and the teat may flatten or collapse. A valve can allow air to enter the bottle and help regulate the pressure inside it. Different bottle designs achieve this in different ways, and some have additional components intended to keep air away from the milk pathway. The term "anti-colic" is much broader than the mechanical function of the valve, though. A valve can change airflow through the bottle; it cannot guarantee that a baby will not have colic, wind or unsettled behaviour. Colic and digestive discomfort have many possible causes, and a bottle described as "anti-colic" should therefore be understood as a description of the bottle's design rather than a promise about what your baby will experience. The material a teat is made from Most modern bottle teats are made from silicone or rubber. These materials do not behave in exactly the same way. Silicone is a synthetic material. It is generally clear, relatively firm and does not contain natural rubber latex. Natural rubber, on the other hand, is derived from natural rubber latex and tends to be softer and more flexible. Natural rubber products can also change more noticeably with repeated use and sterilisation. For most families, the choice may simply come down to how the teat feels, how the baby responds to it, how durable it is and how well it fits the bottle system. Latex sensitivity is another consideration. If a baby or caregiver has a known natural rubber latex allergy or sensitivity, the material needs to be checked carefully rather than assuming that all soft or rubber-like teats are silicone. Whichever material you choose, inspect the teat regularly. Teats can become damaged, split, sticky or otherwise deteriorate with use and sterilisation. NHS guidance specifically recommends checking bottles and teats for damage and replacing damaged equipment (NHS, 2026a; NHS, 2026c). Glass, plastic or collapsible bottles? The bottle itself can be made from several materials, with glass and plastic being the most common choices. Glass bottles are durable and can be straightforward to clean, although they are heavier and can break if dropped. Plastic bottles are lighter and easier to carry, which can be useful for everyday life, but they can become scratched or worn over time and should still be checked regularly. Some bottles are soft or collapsible. These can be particularly useful in specialist feeding situations, but a soft bottle is not simply another bottle to squeeze whenever a baby seems to need more milk. Some specialist systems require the caregiver to use the bottle in a very specific way. This is particularly important for babies with a cleft palate, where specialist bottles may use squeezing or valves to help provide milk. These systems should only be used following guidance from the baby's cleft feeding team. For everyday bottle feeding, there is no requirement to buy an expensive bottle. NHS guidance states that simple bottles which are easy to wash and sterilise are probably best (NHS, 2026a). What about anti-colic and self-sterilising bottles? Anti-colic bottles often combine a valve or venting system with a particular bottle and teat design. The mechanical features can be useful, but the name "anti-colic" should not be interpreted as a guarantee that a baby will not experience wind or colic. A self-sterilising bottle is designed so that the bottle components can be assembled in a particular way and sterilised, usually using steam in a microwave according to the manufacturer's instructions. This can be convenient, but it does not remove the need to clean the bottle properly before sterilisation. Sterilisation and cleaning are separate steps. Milk residue needs to be removed before the sterilisation process. If you are considering a bottle with several valves, membranes and separate components, it is also worth thinking about whether you will be able to clean every part thoroughly and consistently. A theoretically sophisticated bottle is not particularly useful if it becomes difficult to clean properly. Sterilising still matters Whatever bottle or teat you choose, hygiene remains important. NHS guidance recommends sterilising bottles, teats and other feeding equipment until your baby is at least 12 months old. Equipment should be cleaned in hot, soapy water as soon as possible after feeds and rinsed in clean, cold running water before sterilisation (NHS, 2026c). There are several recognised methods, including cold-water sterilising solution, steam sterilising and boiling. If boiling is used, NHS guidance recommends boiling the equipment for at least 10 minutes and checking that the equipment is safe to boil. Teats can become damaged more quickly with boiling, so they should be inspected regularly (NHS, 2026c). Steam sterilisers and self-sterilising bottles should be used according to the manufacturer's instructions. Cold-water sterilising solutions also need to be prepared and changed according to the instructions. The important part is not which sterilising method looks most impressive. It is that the method is suitable for the equipment and used consistently. Babies with cleft palate need specialist advice Babies born with a cleft lip and/or palate can have very different feeding requirements because the opening in the palate can make it difficult to create the seal and vacuum normally used for feeding. Specialist bottles and teats are available for babies born with a cleft. CLAPA supplies specialist feeding equipment used and recommended by NHS Cleft Nurse Specialists, and advises families to speak with their Cleft Nurse Specialist about which equipment is appropriate (CLAPA, 2026a; CLAPA, 2026b). Some specialist systems work by squeezing a soft bottle while the baby sucks, while others use valves or specially designed teats. These systems need to be demonstrated and used according to the advice of the baby's cleft team. This is not an area where I would recommend buying a specialist bottle based simply on an online description. The baby's cleft anatomy, feeding ability and the equipment available through their specialist service all need to be considered together. What if your baby refuses the teat? Bottle refusal can be surprisingly complicated. Sometimes the issue is the teat itself, but sometimes it is the flow, feeding position, temperature of the milk, the person offering the bottle, the baby's previous feeding experiences or simply the fact that the baby is not interested in drinking at that particular moment. A baby who has previously breastfed may also respond differently to a bottle from a baby who has always bottle fed. If you are trying different approaches, it can be helpful to change one variable at a time. Changing the bottle, teat, flow, feeding position, caregiver and routine all at once makes it very difficult to work out what your baby is responding to. Repeatedly persuading or forcing a baby to take a bottle can also turn feeding into a stressful experience. Watching your baby's communication and allowing pauses is part of responsive bottle feeding. I have written more about this in When Your Baby Suddenly Refuses the Bottle. If bottle feeding continues to be difficult, it is worth considering the feeding itself rather than simply buying another bottle. Teat shape and flow, oral coordination, positioning, respiratory factors and other aspects of feeding can all contribute. Bottle-feeding difficulties do not automatically mean that a baby has a tongue-tie, and a tongue-tie does not automatically explain every bottle-feeding difficulty. A bottle is not always necessary There are circumstances where a baby needs to receive expressed breast milk, donor milk where appropriate or infant formula but does not need to use a bottle. Depending on their age, development, health and feeding ability, an alternative feeding method may sometimes be considered. This might include cup feeding or another method recommended by an appropriately trained healthcare professional. For an older breastfed baby who can sit independently and is developmentally ready for a cup, there may not be a need to introduce a bottle simply because they need another way of receiving milk. Going directly to a cup can sometimes be a practical option. I have written more about the different possibilities in Alternative Feeding Methods for Babies. The appropriate method depends on the individual baby. Alternative feeding methods should not be selected simply because a particular method is described online as being "better", and some methods need to be demonstrated face to face because the safety of the method depends on the baby's ability to coordinate sucking, swallowing and breathing. If you are using a bottle alongside breastfeeding Combination feeding can work in many different ways. Some babies have one or two bottles a day and breastfeed for the remaining feeds. Others have expressed milk or formula at different times of the day, or alternate between breast and bottle according to what works for their family. If maintaining breastfeeding is important to you, the way the bottle is offered may be worth considering alongside the bottle and teat themselves. Paced bottle feeding can give your baby more opportunity to control the speed of the feed, take pauses and communicate when they have had enough. Holding the bottle relatively horizontally rather than allowing milk to pour continuously into the mouth is one part of this approach. I have written more about this in How to Pace Bottle Feeds: A Calm Practical Guide. Position can also make a difference. Some babies are more comfortable in one bottle-feeding position than another, particularly when they are managing a faster flow or are still developing their suck-swallow-breathe coordination. You can read more in Bottle Feeding Positions. A broad, gradually tapered teat combined with responsive or paced feeding may be a useful practical approach for some babies moving between breast and bottle. What it cannot do is guarantee that a baby will avoid teat preference, continue breastfeeding or experience exactly the same mechanics as breastfeeding. The 2025 UK research into bottles marketed as "breast-like" is particularly useful here. It found that manufacturers commonly make claims about supporting combination feeding, reducing bottle refusal, preventing nipple confusion and reproducing breastfeeding physiology, but found very little high-quality scientific evidence to support these claims (Maxwell, Self and Bould, 2025). That does not mean that families should avoid trying different teats. It simply means that the choice is better viewed as an individual feeding decision than as a guarantee attached to a particular brand. There is no perfect bottle The most expensive bottle is not necessarily the most suitable bottle, and a bottle described as "natural", "physiological" or "breast-like" is not automatically going to work better for your baby. At the same time, it is reasonable to pay attention to the shape, flexibility, material and flow of the teat because these characteristics really can affect the mechanics of bottle feeding. Research shows that babies can adapt to different teat characteristics, but that does not mean every baby will respond to every teat in the same way (Lagarde et al., 2019; Kotowski et al., 2020). For one baby, a broad tapered teat may feel comfortable. Another may manage a different shape more effectively. One baby may need a slower flow for several months, while another may become frustrated by the same flow. A baby who feeds comfortably from a particular teat at three months may respond differently as their mouth and feeding skills develop. The useful question is therefore not simply "Which bottle is the best?" It is "How is my baby managing this bottle and teat?" Are they able to maintain a comfortable seal? Are they able to coordinate sucking, swallowing and breathing? Is the flow manageable? Are feeds comfortable rather than exhausting? Are they able to pause and communicate when they need a break? Are they taking enough milk for their individual needs? Those questions tell you much more about whether a bottle is working than the name printed on the packet. References CLAPA (2026a) About CLAPA's services for the UK cleft community. Cleft Lip and Palate Association. Available at: https://clapa.com/about-clapa/what-we-do/ CLAPA (2026b) Feeding babies born with a cleft. Cleft Lip and Palate Association. Available at: https://clapa.com/support-and-community/for-parents-and-families/feeding-babies-born-with-a-cleft/ da Costa, S.P., van den Engel-Hoek, L. and Bos, A.F. (2008) 'Sucking and swallowing in infants with very low birth weight: the effect of different bottle nipples', Acta Paediatrica, 97(4), pp. 473–476. doi:10.1111/j.1651-2227.2008.00704.x. Available at: https://pubmed.ncbi.nlm.nih.gov/18393901/ Eren, M., Bilgin, S. and Kara, B. (2015) 'Feeding an infant with high arched palate by high flow rate bottle nipple', Asia Pacific Journal of Clinical Nutrition, 24(4), pp. 756–758. doi:10.6133/apjcn.2015.24.4.16. Available at: https://pubmed.ncbi.nlm.nih.gov/26693762/ Hummel, P. and Herrmann, W. (1989) 'Physiologic sucking performance and the shape of the oral cavity in infants and young children with respect to the design of nipples for nursing bottles and pacifiers', Fortschritte der Kieferorthopädie, 50(5), pp. 384–391. doi:10.1007/BF02171173. Available at: https://pubmed.ncbi.nlm.nih.gov/2583621/ Kotowski, J., Fowler, C., Hourigan, C. and Orr, F. (2020) 'Bottle-feeding an infant feeding modality: An integrative literature review', Maternal & Child Nutrition, 16(2), e12939. doi:10.1111/mcn.12939. Available at: https://pubmed.ncbi.nlm.nih.gov/31908144/ Lagarde, M.L.J., van Alfen, N., de Groot, S.A.F., Geurts, A.C.H. and van den Engel-Hoek, L. (2019) 'Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study', BMC Pediatrics, 19, 477. doi:10.1186/s12887-019-1859-y. Available at: https://pubmed.ncbi.nlm.nih.gov/31805974/ Maxwell, C., Self, B. and Bould, K. (2025) 'A descriptive investigation of infant feeding bottles marketed in the UK designed to replicate breastfeeding and the evidence that underpins them', Maternal & Child Nutrition, 21(3), e70008. doi:10.1111/mcn.70008. Available at: https://pubmed.ncbi.nlm.nih.gov/40023778/ NHS (2026a) Bottle feeding advice. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/advice/ NHS (2026b) What you need for formula feeding. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/how-to-make-up-a-feed/things-you-need-for-formula-feeding/ NHS (2026c) Sterilising baby bottles. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/sterilising-baby-bottles/ Pados, B.F., Park, J. and Dodrill, P. (2019) 'Know the flow: Milk flow rates from bottle nipples used in the hospital and after discharge', Advances in Neonatal Care, 19(1), pp. 32–41. doi:10.1097/ANC.0000000000000538. Available at: https://pubmed.ncbi.nlm.nih.gov/30028734/ Segami, Y., Mizuno, K., Taki, M. and Itabashi, K. (2013) 'Perioral movements and sucking pattern during bottle feeding with a novel, experimental teat are similar to breastfeeding', Journal of Perinatology, 33, pp. 319–323. doi:10.1038/jp.2012.113. 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There is more than one way to hold a baby for a bottle feed. The traditional semi-upright, cradle-like position is familiar to many families and is often the position shown in general bottle-feeding guidance. However, it is not the only option. Some babies seem more comfortable in a different position, particularly if they are finding the flow of milk difficult to manage, are still developing their suck-swallow-breathe coordination, or are moving between breast and bottle. The position you choose can affect how your baby is supported, how easily you can see their face and respond to their feeding cues, and how the milk reaches their mouth. There is no single bottle-feeding position that is right for every baby, and exploring different positions can sometimes make feeding more comfortable for both of you. What can be in a bottle? A bottle may contain expressed breast milk, infant formula, or a combination of both. For babies under 6 months, milk feeds provide both nutrition and hydration. Correctly prepared formula already contains water as part of the feed, so water should not be added to or used to dilute formula. Expressed breast milk is still breast milk, but feeding expressed milk from a bottle is not necessarily identical to feeding directly at the breast. Human milk naturally varies in composition, including its fat content. Research has also found that the way milk is expressed can affect the composition of the milk obtained. A systematic review found that expression technique affected fat content, although the available studies were limited and did not demonstrate the same effect on protein or lactose content (Çınar and Karakaya Suzan, 2021). This means expressed breast milk should not simply be assumed to have exactly the same composition as the milk an infant receives during direct breastfeeding. There is no single fixed composition of "breast milk", because human milk naturally varies and the milk obtained can also be influenced by how and when it is expressed. What makes a comfortable bottle-feeding position? A useful bottle-feeding position is one in which your baby is well supported but still has enough freedom to move their head, mouth and body. Being able to see your baby's face is particularly important because their facial expression, breathing, movements and feeding cues can all tell you something about how the feed is going. The NHS recommends holding a baby in a semi-upright position for bottle feeds, with their head supported so they can breathe and swallow comfortably (NHS, 2023). The NHS also recommends watching the baby and responding to cues that they need a break rather than expecting them to continue until the bottle is empty (NHS, 2023). Beyond these general principles, there are several positions that can be explored. The traditional semi-upright position The traditional semi-upright position is probably the one most people picture when they think about bottle feeding. Your baby is held close to your body, supported along your arm, with their head higher than their bottom and their head and neck comfortably supported. For some babies, this is a very comfortable and familiar way to feed. It can also make it easy for the caregiver to maintain eye contact, notice feeding cues and enjoy the closeness of the feed. However, the position itself does not determine how quickly milk reaches your baby. If milk is flowing continuously or too quickly, a baby may have fewer opportunities to pause and regulate the feed themselves. This is one reason that positioning needs to be considered alongside the bottle, teat, milk flow and the way the feed is offered. The NHS advises against forcing a baby to finish a bottle because this can result in overfeeding (NHS, 2023). Upright on your lap, facing outwards Some babies seem to prefer being held more upright, particularly when they are alert and interested in their surroundings. One option is to sit your baby supported on your lap, facing outwards, while keeping them close and providing whatever support they need around their body, head and neck. This can provide a very different experience from being cradled across the caregiver's body. It may give a baby who dislikes feeling enclosed a little more freedom to look around, while still allowing the caregiver to remain close and responsive. The important consideration is whether you can still see your baby's face and observe how they are managing the feed. If the position means that the caregiver cannot see the baby's face, another responsible adult should be able to observe the baby throughout the feed. Elevated side-lying Elevated side-lying is another position that has received particular attention in research involving premature babies and infants with developing feeding skills. In this position, the baby is supported on their side with their body well aligned and their head slightly elevated. The caregiver remains close and can see the baby's face throughout the feed. Research in preterm infants has explored semi-elevated and elevated side-lying positions in relation to feeding performance and physiological stability (Clark et al., 2007; Park et al., 2014; Girgin, Gözen and Karatekin, 2018; Raczyńska and Gulczyńska, 2019). Feed Eat Speak has also described elevated side-lying as an option that may be explored with newborns and babies experiencing feeding difficulties (Zimmels, 2018). Although much of the research relates specifically to premature infants, the position can also be considered as one of several options for a term baby who is finding a conventional bottle-feeding position difficult. A familiar breastfeeding-style position For a baby who normally breastfeeds, the transition to a bottle can involve more than simply introducing a different container. The position of the baby's body and the closeness of the caregiver may also feel different. Some families therefore find it helpful to experiment with a position that has elements of the baby's familiar breastfeeding position. This might be a cross-cradle-style position, with the baby's body supported across the caregiver, or a side-by-side or under-arm position in which the baby is supported alongside the caregiver's body. The purpose of the latter is not literally to put the baby "in the armpit". Rather, it is a way of using a familiar body position that may feel more recognisable to a baby who is accustomed to feeding at the breast. There is no guarantee that a familiar position will make a baby accept a bottle, but it can be one of several things worth trying when the change from breast to bottle is proving difficult. Positions for premature or smaller babies Premature and smaller babies may need more individualised support because their ability to coordinate sucking, swallowing and breathing can still be developing. The research into elevated and semi-elevated side-lying has particularly focused on preterm infants, with studies examining how different positions affect feeding performance and physiological responses (Clark et al., 2007; Park et al., 2014). For a premature baby, a baby with complex medical needs or an infant experiencing significant feeding difficulties, positioning may need to be tailored with support from the neonatal or infant-feeding team. A position that is useful for one baby is not automatically appropriate for another. What about the bottle and teat? Position is only one part of bottle feeding. The bottle itself, the shape and flexibility of the teat and the rate at which milk flows can all influence how a baby experiences a feed. It is very common for families to recommend products to one another, but a bottle or teat that works beautifully for one baby may be much less suitable for another. Babies have different oral dimensions, palate shapes and suck-swallow-breathe coordination, so there is no reason to expect one particular teat shape or bottle system to suit every baby. Marketing can also make particular products sound as though they have universal advantages. It is worth being cautious about this, particularly when a product is presented as the answer to a feeding problem without considering the individual baby. If you want to explore the different features of bottle teats in more detail, see Bottle Teat Shapes. Position is not the same as paced bottle feeding Positioning and pacing are closely related, but they describe different things. Positioning is about how your baby's body is supported while they feed. Pacing is about how the flow of milk is offered and how your baby is given opportunities to pause. A baby can therefore be held in a comfortable position and still find the milk flow too fast. Equally, changing the position alone will not necessarily resolve a feeding difficulty. For a more detailed explanation of pacing, see How to Pace Bottle Feeds: A Calm Practical Guide. When a baby refuses a bottle: movement and sensory changes For some babies, changing the whole environment around the feed can be worth exploring. Rather than sitting still and offering the bottle in the same position repeatedly, some families find that their baby is more willing to accept a bottle while being held upright and gently walked or swayed. This is sometimes described as motion feeding. The movement may provide a familiar sensory experience and can be particularly worth considering when a baby becomes upset as soon as they are settled into a conventional bottle-feeding position. Gentle movement, rather than vigorous bouncing or rocking, can sometimes help a baby settle enough to explore the bottle. A change in the sensory environment may also be helpful. Some babies respond to a calm voice, singing, a familiar lullaby or gentle background sound such as white noise while they are being offered a bottle. These approaches are quite different from using a screen to distract an infant, and screens are not necessary for this purpose. The aim should not be to distract a baby so thoroughly that they take the bottle without noticing what they are doing. Instead, a calm change in movement, sound or surroundings may help some babies feel more settled and receptive to trying something unfamiliar. If a baby consistently refuses a bottle, it is worth considering why rather than repeatedly trying to persuade them to drink. The feeding position, teat shape and flow, temperature of the milk, the person offering the bottle and whether the baby is accustomed to breastfeeding can all be relevant. Bottle propping: this is dangerous Bottle propping is sometimes presented as a convenient way to allow a baby to feed without the caregiver having to hold the bottle. It may involve balancing the bottle against a blanket, cushion or toy, using a specially designed holder, or buying a product intended to keep the bottle in the baby's mouth. This is not a safe way to bottle feed. A baby who is feeding from a propped bottle cannot reliably control what happens if the flow becomes too much for them. They may cough, choke, aspirate milk or become unable to breathe properly, while the adult may not recognise what is happening quickly enough to intervene. The danger is serious enough that the UK Office for Product Safety and Standards has issued safety alerts about baby self-feeding products and prop feeders. These products are designed to allow a baby to bottle feed with little or no assistance from a caregiver and have been identified as presenting a risk of serious harm or death from choking or aspiration pneumonia (OPSS, 2022; OPSS, 2025). Some of these products have been removed from the UK market, yet similar products and "hands-free" feeding gimmicks can still appear online. The fact that something is being sold or marketed specifically for babies does not mean that it has been shown to be safe. The NHS is equally clear that babies should never be left alone with a propped-up bottle because of the risk of choking (NHS, 2023). This is therefore much more than a question of whether bottle propping is "good practice". A baby should never be left to feed from a propped bottle or a self-feeding device. The potential consequences can be fatal. Is there a best bottle-feeding position? There is no single position that every baby needs to use. The traditional semi-upright position may work very well for one baby, while another may settle more comfortably in an elevated side-lying, upright or breastfeeding-style position. A baby's preferred position may also change as they grow and their feeding skills develop. Rather than looking for one "best" position, it can be more helpful to consider how your individual baby is managing the feed. Are they comfortable? Can you see their face? Are they able to breathe and swallow comfortably? Can you recognise when they need a pause? Does the position allow you to respond to their cues? If a baby is regularly coughing, choking, spluttering, losing milk from their mouth, becoming distressed, taking a very long time to feed or struggling to coordinate feeding and breathing, changing position may be worth exploring, but persistent feeding difficulties deserve individual assessment rather than simply trying different positions indefinitely. References Clark, L., Kennedy, G., Pring, T. and Hird, M. (2007) ‘Improving bottle feeding in preterm infants: investigating the elevated side-lying position’, Infant, 3(4), pp. 154–158. Çınar, N. and Karakaya Suzan, Ö. (2021) ‘Investigation of the effect of human milk expression techniques on milk content: a systematic review’, Journal of Tropical Pediatrics, 67(6), fmab108. Girgin, B.A., Gözen, D. and Karatekin, G. (2018) ‘Effects of two different feeding positions on physiological characteristics and feeding performance of preterm infants: a randomized controlled trial’, Journal for Specialists in Pediatric Nursing, 23(2), e12214. NHS (2023) ‘Bottle feeding advice’. NHS. NHS (2023) ‘Bottle feeding your baby’. NHS Best Start in Life. Office for Product Safety and Standards (OPSS) (2022) ‘Product Safety Alert: Baby Self-Feeding Pillows / Prop Feeders (PSA3)’. GOV.UK. Office for Product Safety and Standards (OPSS) (2022) ‘Product Safety Alert: Baby Self-Feeding Products (PSA4)’. GOV.UK. Office for Product Safety and Standards (OPSS) (2025) ‘Warning of new variant of dangerous baby self-feeding products’. GOV.UK. Park, J., Thoyre, S., Knafl, G.J., Hodges, E.A. and Nix, W.B. (2014) ‘Efficacy of semielevated side-lying positioning during bottle-feeding of very preterm infants’, Journal of Perinatal & Neonatal Nursing, 28(1), pp. 69–79. Raczyńska, A. and Gulczyńska, E. (2019) ‘The impact of positioning on bottle-feeding in preterm infants (≤34 GA): a comparative study of the semi-elevated and the side-lying position – a pilot study’, Developmental Period Medicine, 23(2), pp. 117–124. Zimmels, S. (2018) ‘Elevated side lying bottle feeding’, Feed Eat Speak, 14 August.

Breast milk is much more than a source of food. It is a complex, biologically active fluid containing water, fats, carbohydrates, proteins, vitamins, minerals and a range of components involved in immune protection, digestion and development. Its composition changes during the early days after birth, throughout individual feeds and across the entire period of lactation (Ballard and Morrow, 2013). These changes are a normal part of lactation. Colostrum, produced in the first days after birth, differs from mature milk in its composition and concentration of many components. As lactation progresses, breast milk continues to provide energy and nutrients alongside antibodies, enzymes, hormones and other biologically active substances. Its composition also varies between individuals and according to the stage of lactation (Ballard and Morrow, 2013; Dror and Allen, 2018). The main components of breast milk Water Breast milk is approximately 87% water, making it an important source of hydration as well as nutrition. For a healthy baby who is exclusively breastfed, breast milk provides the fluid needed during the first six months of life, including in warm weather. Additional water is not routinely required during this period (WHO, 2023). Carbohydrates Lactose is the principal carbohydrate in breast milk. It provides energy and contributes to the absorption of certain minerals. Breast milk also contains human milk oligosaccharides (HMOs), a diverse group of complex carbohydrates that are not primarily digested by the infant. Instead, many HMOs help shape the developing gut microbiome and can act as decoy receptors for certain pathogens, contributing to the protection of the infant's intestinal environment (Bode, 2012). The composition of HMOs varies between individuals, partly because of genetic differences. This is one example of how breast milk contains components that do more than provide calories. Fats Fat is an important source of energy for a growing infant and contributes to the development of the brain, nervous system and other tissues. Breast milk contains a range of fatty acids, including essential fatty acids that the body cannot produce in sufficient quantities on its own. Fat concentration varies between individuals, between feeds and as milk is removed from the breast. It is influenced by factors including how full the breast is and the stage of milk removal. This natural variation is one reason that breast milk should not be thought of as having a single, fixed nutritional composition (Ballard and Morrow, 2013; Kent et al., 2006). Proteins Breast milk contains proteins that provide amino acids for growth and development, as well as proteins with other functions. These include whey and casein proteins, enzymes and immune-related proteins such as lactoferrin. Lactoferrin binds iron and has antimicrobial properties, while other proteins help with digestion, nutrient transport and immune function. The relative proportions of proteins change over the course of lactation, with colostrum having a different profile from mature milk (Ballard and Morrow, 2013). Vitamins and minerals Breast milk contains vitamins and minerals required for growth and development. The concentrations of some nutrients are influenced by maternal nutritional status, while others are more tightly regulated by the body. Breast milk is not identical in composition for every lactating person, and some nutrients, including vitamin D, may require particular consideration under UK guidance. Vitamin supplementation should be considered in line with current NHS advice and the individual circumstances of the infant and lactating person, rather than assuming that breast milk always provides every nutrient in the same quantity (NHS, n.d.). Antibodies and other immune components Breast milk contains antibodies, immune cells and other components that contribute to immune protection. Secretory immunoglobulin A (sIgA) is a particularly important antibody in human milk. It helps protect the surfaces of the infant's mouth, gut and respiratory tract by binding to microbes and supporting mucosal defence. Breast milk also contains immune cells, cytokines, enzymes and other substances involved in the regulation of immune responses. These components are part of a wider biological system that supports the infant while their own immune system continues to develop (Ballard and Morrow, 2013; Verhasselt et al., 2024). Enzymes, hormones and growth factors Breast milk contains enzymes that assist with digestion and other biological processes, alongside hormones and growth factors involved in metabolism, intestinal development and physiological regulation. Their presence illustrates that breast milk is not simply a mixture of nutrients; it is a biologically active fluid that interacts with the developing infant in several ways (Ballard and Morrow, 2013; Cacho and Lawrence, 2017). How breast milk is made Breast milk is produced in specialised cells within structures called alveoli in the breast. These cells take up substances from the maternal circulation and use them to synthesise milk components. Breast milk is therefore made using materials supplied through the blood, but it is not simply blood that has been filtered into milk. The mammary gland actively produces and transports the different components of milk (Ballard and Morrow, 2013). Two hormones play important roles in lactation. Prolactin supports milk synthesis, while oxytocin causes the small muscle-like cells surrounding the alveoli to contract, moving milk towards the ducts and nipple. This movement is known as the milk ejection reflex, often called let-down. Milk ejection can occur more than once during a feed, and its timing and strength vary between individuals and circumstances (Neville, 2001). Milk production is also influenced by milk removal. As milk is regularly removed, the breast receives signals that support continued production. When milk remains in the breast for longer periods, production generally slows. This is one reason that effective milk removal and the frequency of feeding or expressing can influence milk supply (Kent et al., 2006). The Association of Breastfeeding Mothers (2023) explains the process in its illustrated and animated video, How Breastmilk Is Made, illustrated and animated by JoJo Ford. How a baby's saliva may relate to breast milk The relationship between a baby's mouth and breast milk is an area of interest because lactation involves interaction between the infant and the lactating person's immune system. Breast milk contains antibodies and other immune components, and maternal immune responses can influence the antibodies present in milk. These responses are part of the body's wider immune activity, including responses to microbes encountered by the mother (Verhasselt et al., 2024). It is sometimes explained that a baby's saliva is absorbed through the nipple or areola and directly signals the mother's body to produce specific antibodies for that baby. Although communication between the infant and the lactating person's immune system is biologically plausible and an area of ongoing research, this precise pathway should not be presented as an established mechanism. The extent to which infant saliva directly changes the specific antibody content of breast milk, and how this might occur, is not yet fully understood. What is established is that breast milk contains immune components that support the infant's mucosal defences, and that its composition is dynamic. The potential for interactions between the infant and the lactating person's immune system is an important area of research, but it is helpful to distinguish what is known about breast milk's immune function from explanations of how particular changes might be triggered. Does maternal diet affect breast milk? A varied, balanced diet supports the nutritional health of the lactating person. Some aspects of breast milk composition, including the profile of certain fatty acids, can be influenced by maternal dietary intake. However, the relationship between diet and the overall nutritional composition of breast milk is complex, and changes in what someone eats do not reliably produce a predictable increase in the total fat content of their milk or their baby's weight gain (Bravi et al., 2016; Dror and Allen, 2018). There is no special diet that is required to produce good-quality breast milk. In general, a balanced diet that includes a variety of foods is appropriate, and drinking to thirst is a reasonable way to maintain hydration. Drinking excessive amounts of fluid does not, by itself, increase milk production. Where there are concerns about a baby's weight gain, it is important to consider the whole feeding picture. This includes how effectively the baby feeds, milk transfer, feeding frequency, milk production and the infant's clinical circumstances. Changing the lactating person's diet alone is not a reliable way to address poor weight gain. How breast milk changes during a feed The fat concentration of breast milk changes as milk is removed from the breast. Rather than being divided into two distinct types, milk has a changing composition throughout a feed. Fat concentration generally increases as the breast becomes less full, although the pattern varies according to breast fullness, the interval since the previous feed and the circumstances of milk removal (Daly et al., 1993; Kent et al., 2006). The terms foremilk and hindmilk have traditionally been used to describe milk collected towards the beginning and end of a feed. However, these terms can give the misleading impression that one type of milk stops and another begins at a specific point. In reality, there is no abrupt transition. Milk with a lower fat concentration and milk with a higher fat concentration are part of the same continuously changing fluid, and their relative proportions vary throughout milk removal. The fat concentration at any particular moment depends on the circumstances of feeding. Milk at the beginning of one feed may have a different fat concentration from milk at the beginning of another. There is no universal point at which milk becomes higher in fat, and no requirement for a baby to reach a particular stage of a feed before receiving nutritionally valuable milk (Daly et al., 1993; Kent et al., 2006). Milk ejection and changes in milk fat Changes in fat concentration should not be confused with the milk ejection reflex, commonly called let-down. Milk ejection occurs when oxytocin causes specialised cells surrounding the milk-producing alveoli to contract, moving milk into the ducts and towards the nipple. This response can occur more than once during a feed (Neville, 2001). Milk ejection describes the movement of milk, whereas changes in fat concentration describe its composition. Although milk ejection and milk removal are related, a let-down is not a switch between two types of milk. Milk composition continues to vary as feeding progresses, including around successive milk ejections. Understanding concerns about milk fat The expression foremilk–hindmilk imbalance is sometimes used when families are concerned about symptoms such as green stools, wind, fussiness or frequent feeding. However, these observations alone do not establish that an infant is receiving too much milk with a lower fat concentration or too little milk with a higher fat concentration. Milk fat varies naturally, and research examining milk macronutrients has not established a consistent relationship that would allow a particular symptom or stool colour to be used to identify an imbalance (Brockway et al., 2024). It is therefore important not to draw conclusions about milk composition from these observations alone. There is no universal requirement to feed for a specified number of minutes or to follow a rigid schedule to ensure that a baby receives milk with a higher fat concentration. Feeding patterns need to be considered in the context of the individual infant, including feeding effectiveness, growth and any clinical concerns. Understanding a baby's feeding cues can help families respond to their individual needs without trying to manage feeding according to perceived changes in milk fat. For more information, see Recognising Feeding Cues in Young Babies. Where persistent symptoms, feeding difficulties or concerns about weight gain are present, assessment of the infant and the overall feeding pattern is more informative than attempting to correct an assumed imbalance. How breast milk changes as a child grows Breast milk changes throughout lactation. Colostrum, produced in the first days after birth, has a different composition from mature milk, including differences in its concentration of proteins and immune components. As milk production becomes established, its composition changes to meet the needs of the growing infant, although individual variation remains considerable (Ballard and Morrow, 2013). Breast milk continues to provide energy, nutrients and biologically active components beyond the first year of life. Research has found that milk composition can change during prolonged lactation, including changes in some macronutrients and immune components. These changes do not mean that breast milk loses its value as a child grows (Lackey et al., 2021). The World Health Organization recommends exclusive breastfeeding for the first six months, followed by the introduction of complementary foods alongside continued breastfeeding to two years and beyond (WHO, 2023). As children grow, complementary foods become necessary to meet their increasing nutritional requirements. Breast milk continues to contribute nutrition and biological support alongside those foods, including during natural-term breastfeeding, which may continue for several years until the child chooses to wean. A final perspective on breast milk Breast milk is a complex, biologically active food that provides energy, nutrients and immune components. Its composition changes naturally from colostrum in the early days after birth to mature milk and the milk produced during prolonged breastfeeding. These changes are part of normal lactation and do not mean that breast milk loses its value as a child grows. Understanding the biology of lactation can help explain why milk composition varies, how milk production works and why the idea of two separate types of milk is misleading. However, lactating parents do not need to understand these mechanisms to breastfeed. They do not need to monitor milk fat, identify different stages of milk composition or learn the science of lactation to feed their baby. The science behind breast milk is fascinating, but it should reassure families about the remarkable biology of lactation rather than create another expectation they feel they must meet. Where feeding is difficult or there are concerns about growth, appropriate support can help families understand what is happening and identify whether anything needs attention. References Association of Breastfeeding Mothers (2023) How Breastmilk Is Made [YouTube video]. Illustrated and animated by JoJo Ford. Available at: https://www.youtube.com/watch?v=5-i4tm7mGnc Ballard, O. and Morrow, A.L. (2013) ‘Human milk composition: nutrients and bioactive factors’, Pediatric Clinics of North America, 60(1), pp. 49–74. doi: 10.1016/j.pcl.2012.10.002. Bode, L. (2012) ‘Human milk oligosaccharides: every baby needs a sugar mama’, Glycobiology, 22(9), pp. 1147–1162. doi: 10.1093/glycob/cws074. Bravi, F. et al. (2016) ‘Impact of maternal nutrition on breast-milk composition: a systematic review’, The American Journal of Clinical Nutrition, 104(3), pp. 646–662. doi: 10.3945/ajcn.115.120881. Brockway, M.B. et al. (2024) ‘Human milk macronutrients and child growth and body composition in the first two years: a systematic review’, Advances in Nutrition, 15(1), article 100149. doi: 10.1016/j.advnut.2023.100149. Cacho, N.T. and Lawrence, R.M. (2017) ‘Innate immunity and breast milk’, Frontiers in Immunology, 8, article 584. doi: 10.3389/fimmu.2017.00584. Daly, S.E.J., Di Rosso, A., Owens, R.A. and Hartmann, P.E. (1993) ‘Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk’, Experimental Physiology, 78(6), pp. 741–755. doi: 10.1113/expphysiol.1993.sp003722. Dror, D.K. and Allen, L.H. (2018) ‘Overview of nutrients in human milk’, Advances in Nutrition, 9(Suppl. 1), pp. 278S–294S. doi: 10.1093/advances/nmy022. Kent, J.C. et al. (2006) ‘Volume and frequency of breastfeedings and fat content of breast milk throughout the day’, Pediatrics, 117(3), pp. e387–e395. doi: 10.1542/peds.2005-1417. Lackey, K.A. et al. (2021) ‘Breastfeeding beyond 12 months: is there evidence for health impacts?’, Annual Review of Nutrition, 41, pp. 283–308. doi: 10.1146/annurev-nutr-043020-011242. National Health Service (NHS) (n.d.) Breastfeeding vitamins. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/healthy-diet-when-breastfeeding/breastfeeding-vitamins/ Neville, M.C. (2001) ‘Anatomy and physiology of lactation’, Pediatric Clinics of North America, 48(1), pp. 13–34. doi: 10.1016/S0031-3955(05)70283-2. Verhasselt, V. et al. (2024) ‘Antibodies in breast milk: pro-bodies designed for healthy newborn development’, Immunological Reviews, 328(1), pp. 192–204. doi: 10.1111/imr.13411. World Health Organization (WHO) (2023) WHO guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization.

Switch Nursing: Supporting Milk Supply, Milk Transfer and Infant Weight Gain Switch nursing is a breastfeeding technique that involves offering each breast more than once during a feed. It can be used when milk production needs increasing, when a baby is not maintaining active feeding or when an infant is struggling to gain weight as expected. By changing breasts when sucking and swallowing slow, the aim is to encourage renewed feeding activity, stimulate further milk ejection reflexes and support effective milk removal (Riordan and Wambach, 2016; La Leche League Canada, 2024). Switch nursing is not simply a way to manage a baby who comes off the breast, dozes and then signals to feed again. It is a practical technique that may form part of a wider feeding plan, particularly when milk production or milk transfer needs support. Understanding when and how to use it, alongside other strategies, helps ensure that feeding advice addresses the needs of the individual feeding dyad rather than focusing solely on how long a baby remains at the breast. What is switch nursing? Switch nursing involves offering one breast until the baby's active sucking and swallowing slows, then offering the other breast. If active feeding slows again, the first breast can be offered once more, with further changes of side as appropriate. This may be repeated several times during a single feed, depending on the baby's response and the feeding plan (Riordan and Wambach, 2016; La Leche League Canada, 2024). The intention is to encourage periods of active feeding rather than allowing a baby to spend a prolonged time at the breast with little effective milk transfer. Nutritive sucking is generally characterised by deeper, slower jaw movements and swallowing, whereas non-nutritive sucking tends to involve more rapid, shallow movements with less swallowing. Observing these changes can help identify when a baby may benefit from breast compressions or a change of side (Academy of Breastfeeding Medicine, 2022; University Health Network, 2020). Changing breasts can stimulate another milk ejection reflex, providing an opportunity for the baby to resume more active sucking and swallowing. Repeated breast stimulation may also contribute to maintaining or increasing milk production when combined with effective milk removal across the day and night (Riordan and Wambach, 2016; Kent et al., 2006). Switch nursing does not require equal feeding times on each breast, and there is no universally correct number of switches. The approach depends on the baby's feeding behaviour, milk transfer, clinical needs and the breastfeeding parent's goals. When might switch nursing be useful? Switch nursing may be considered when milk production needs increasing, when a baby becomes sleepy before feeding effectively, or when active sucking and swallowing reduce before sufficient milk has been transferred. It may also be incorporated into a feeding plan when an infant's weight gain is slower than expected and assessment suggests that encouraging more active feeding could help (Riordan and Wambach, 2016; University Hospitals Sussex NHS Foundation Trust, n.d.). When milk production needs increasing, offering both breasts and returning to each side may provide additional stimulation. If a baby is becoming less active as milk flow slows, changing breasts can offer another opportunity for active feeding. Breast compressions can also be used to encourage milk flow before changing sides (La Leche League Canada, 2024). However, frequent feeding does not automatically indicate low milk production. Cluster feeding can be part of normal infant feeding behaviour, and feeding frequency varies between babies and across the day. The significance of frequent feeding depends on the wider picture, including the baby's health, feeding effectiveness, urine output, growth and the breastfeeding parent's experience (Kent et al., 2006; Academy of Breastfeeding Medicine, 2022). Switch nursing is therefore best understood as one technique that may support effective feeding and milk removal, rather than a solution for every unsettled feed or every concern about supply. Where feeding difficulties persist, assessment is needed to establish whether the main concern relates to milk production, milk transfer, infant feeding function or another contributing factor. Combining switch nursing with breast compressions Breast compressions involve gently compressing the breast while the baby is attached, with the intention of encouraging milk flow. When a baby continues sucking but swallowing slows, compression may help the baby receive more milk before changing sides. Once the baby is no longer responding to compression, offering the other breast may encourage renewed sucking and swallowing (La Leche League Canada, 2024; University Hospitals Sussex NHS Foundation Trust, n.d.). The two techniques can be combined according to the baby's response. A caregiver may observe active feeding on the first breast, use breast compressions when swallowing slows, and then offer the other breast if the baby remains interested but is no longer feeding effectively. The sequence can be repeated as appropriate. The aim is to support milk transfer without causing pain or turning feeding into a rigid routine. Breast compression should be comfortable, and the baby should not be forced to remain attached when no longer interested or when feeding appears difficult. Persistent difficulty maintaining attachment, coordinating sucking and swallowing or responding to milk flow warrants further assessment rather than repeated switching alone (Academy of Breastfeeding Medicine, 2022). Positioning, attachment and breast shaping Effective positioning and attachment are important because the baby's ability to maintain a comfortable latch influences milk transfer. If a baby repeatedly slips off the breast, struggles to maintain attachment or causes persistent nipple pain, switching sides may not resolve the underlying difficulty. A feeding assessment can help identify whether positioning, attachment, oral function or another factor needs attention (Academy of Breastfeeding Medicine, 2022; NICE, 2017). Breast shaping can support some babies to achieve an effective attachment by helping the breast fit comfortably within the baby's mouth. The approach needs to take account of the baby's position, the shape and size of the breast, nipple direction and the breastfeeding parent's comfort. Breast shaping, positioning and attachment should be considered together rather than as separate rules that every feeding dyad must follow. For further information, see Breastfeeding Latch and Positioning and How to Improve Infant Latch: Practical Breastfeeding Support. Where attachment remains difficult despite support, the assessment should consider the baby's feeding function and the wider clinical picture. The appearance of a lingual frenulum alone does not establish whether it is affecting feeding; assessment needs to consider tongue function, observed feeding, maternal comfort and milk transfer (NICE, 2017). Supporting milk production Milk production is influenced by hormonal processes and the frequency and effectiveness of milk removal. In the early postnatal period, frequent breastfeeding and effective milk removal are important in establishing production, while ongoing milk removal helps regulate production in response to the infant's needs (de Carvalho et al., 1983; Kent et al., 2006). Where supply needs increasing, switch nursing may be one component of a plan to provide additional breast stimulation. Other measures may include responsive feeding, improving attachment, breast compressions and expressing milk. The appropriate combination depends on the reason for the supply concern and whether the baby can remove milk effectively at the breast (Academy of Breastfeeding Medicine, 2017; Academy of Breastfeeding Medicine, 2022). It is important to distinguish between milk production and milk transfer. A breastfeeding parent may produce sufficient milk, but an infant may struggle to remove it effectively. Alternatively, the infant may feed effectively but the available milk may not meet their needs. Both situations can involve frequent feeding, yet the management approach may differ (NICE, 2017; Kent et al., 2006). Further information is available in Increasing Breast Milk Production. This can help families understand why assessment of milk production and milk removal matters before assuming that supply is the sole explanation for feeding difficulties. Expressing milk and flange fit Expressing may be helpful when an infant is unable to remove sufficient milk directly from the breast, when a feed is missed or ineffective, or when additional stimulation is needed to support milk production. Expressed breast milk can also be offered to the infant when additional intake is required as part of an agreed feeding plan (Academy of Breastfeeding Medicine, 2017; Academy of Breastfeeding Medicine, 2022). The frequency of expressing should reflect the individual circumstances, including the baby's age, feeding effectiveness, milk production and the amount of additional milk required. Where an infant is not transferring milk effectively, expressing may help protect milk production while the underlying difficulty is assessed and addressed. It should not, however, become an unnecessarily burdensome routine without consideration of the mother's recovery, sleep, emotional wellbeing and practical circumstances. Pump choice and flange fit can affect comfort and the experience of expressing. A flange that is unsuitable for the individual breast and nipple may cause discomfort or contribute to ineffective milk removal, so assessment of fit can be valuable when expressing is painful or appears ineffective (Academy of Breastfeeding Medicine, 2022). Families can read more in How to Express Breastmilk and Breast Pump Flange Fitting: Size, Shape, Comfort and Milk Removal. Low weight gain: why weighing alone is not enough When an infant's weight trajectory raises concern, weight measurements are essential for identifying the pattern of growth and monitoring whether progress is improving. However, weighing is a monitoring measure, not an intervention that addresses the cause of inadequate weight gain. NICE recommends a clinical, developmental and social assessment when faltering growth is suspected, alongside a detailed feeding history and direct observation of feeding where appropriate. For milk-fed infants, possible contributing factors include ineffective suckling, ineffective bottle feeding, feeding patterns, the feeding environment, feeding aversion, responses to feeding cues and physical difficulties affecting feeding (NICE, 2017). This distinction is important because a baby may feed frequently without transferring sufficient milk, while another may transfer milk effectively but have an underlying issue affecting milk production or growth. Weight measurements can demonstrate that a concern exists, but they cannot establish the cause by themselves. The assessment and feeding plan must address the factors contributing to the baby's growth trajectory (NICE, 2017). Where weight gain is concerning, timely involvement of an appropriate healthcare professional is a priority. The urgency depends on the baby's age, clinical condition, degree of weight change and other findings. A baby who is unwell, difficult to wake, showing signs of dehydration or feeding substantially less than usual needs urgent clinical assessment rather than further attempts to manage feeding with switch nursing alone (NICE, 2017). An International Board Certified Lactation Consultant (IBCLC) can provide specialist lactation and infant-feeding assessment, including observation of feeding, assessment of milk transfer and support with milk production, expressing and supplementation. The IBCLC can contribute to a feeding plan alongside the GP, health visitor, midwife or paediatric team, according to the baby's clinical needs. Medical assessment remains necessary where illness, dehydration or another health concern needs to be investigated (NICE, 2017; Academy of Breastfeeding Medicine, 2022). The baby's health and adequate nutritional intake must come first. Increasing milk production may be an important part of the plan, particularly where continued breastfeeding is a family goal, but it must not delay ensuring that the infant receives sufficient milk. The plan may include switch nursing, breast compressions, improving attachment, expressing and providing additional milk where clinically indicated. Follow-up should evaluate whether the plan is meeting the baby's nutritional needs and whether the factors contributing to the concern are improving, alongside weight monitoring at intervals appropriate to the clinical situation (NICE, 2017; Kellams et al., 2017). For more information about specialist feeding support, see What is an IBCLC? Feeding Support Explained. Expressed milk, supplementation and supplemental nursing systems Where an infant needs additional milk, the feeding plan should identify how their nutritional requirements will be met while the underlying difficulty is investigated and addressed. Depending on the clinical circumstances, this may involve expressed breast milk, donor human milk where available and appropriate, or infant formula. Supplementation decisions should be based on an assessment of the individual infant rather than a single finding in isolation (Kellams et al., 2017). Providing additional milk does not automatically mean breastfeeding must end. Where maintaining breastfeeding is important to the family, the plan may include continuing to offer the breast when appropriate, expressing to support milk production and reviewing the approach as feeding effectiveness and growth improve. The infant's immediate nutritional needs must remain central to these decisions (Kellams et al., 2017; NICE, 2017). A supplemental nursing system (SNS) delivers additional milk through a fine tube positioned alongside the nipple, allowing the baby to receive milk while feeding at the breast. For some feeding dyads, this can be an option for providing additional milk while maintaining opportunities for direct breastfeeding and breast stimulation. Suitability depends on the baby's feeding ability, the amount of milk required and whether the system can be used reliably and safely with appropriate guidance (La Leche League Great Britain, n.d.; Kellams et al., 2017). An SNS should not be selected simply because an infant has a low weight trajectory. Assessment needs to establish whether the baby can feed effectively at the breast, whether the system is practical for the family and whether the baby's nutritional needs can be met using that method. Other alternative feeding methods may be more appropriate in some circumstances (Kellams et al., 2017). Further information is available in Alternative Feeding Methods for Babies, which discusses different approaches to providing milk when feeding directly at the breast is insufficient or not possible. Supporting maternal mental health during feeding difficulties Breastfeeding difficulties can affect emotional wellbeing, particularly when a mother is worried about milk production, feels that her baby is not satisfied after feeding or is receiving repeated advice to change how she feeds. When an infant is not gaining weight as expected, the responsibility of ensuring adequate intake can add to anxiety, exhaustion and feelings of uncertainty. Frequent feeding, expressing, monitoring intake and attending additional appointments can also become physically and emotionally demanding (World Health Organization, 2022; NICE, 2017). Support should recognise the mother's experience alongside the baby's feeding needs. Reassurance alone may not be sufficient when feeding remains difficult or there are unresolved concerns about milk transfer or weight gain. Clear explanations, an achievable feeding plan, appropriate clinical follow-up and consistent communication between healthcare professionals can help reduce uncertainty and ensure that responsibility for resolving the difficulty does not rest entirely on the mother (World Health Organization, 2022). Switch nursing and other breastfeeding techniques should be offered when appropriate to the feeding assessment, rather than becoming additional tasks that a mother feels she must perform perfectly. Where expressing, supplementation or other feeding methods are needed, these should be discussed sensitively, taking account of the mother's circumstances, feeding goals and emotional wellbeing. Supporting the baby's nutritional needs and supporting the mother's mental health are complementary priorities (World Health Organization, 2022; Kellams et al., 2017). Healthcare professionals should remain alert to signs of significant distress, anxiety or low mood and facilitate access to appropriate perinatal mental-health support when needed. The World Health Organization recommends psychosocial interventions to help prevent postnatal depression and anxiety and emphasises the importance of supportive, respectful postnatal care (World Health Organization, 2022). A compassionate approach acknowledges that feeding experiences can be emotionally complex and that seeking help is not a sign of failure. When feeding difficulties persist Persistent feeding difficulties may involve several contributing factors, including positioning and attachment, maternal comfort, milk production, infant alertness, oral function, coordination, underlying illness or other clinical and environmental influences. NICE recommends considering a range of possible factors when assessing faltering growth, rather than assuming that one explanation accounts for every feeding difficulty (NICE, 2017). A lingual frenulum may be relevant to feeding function in some infants, but its appearance alone cannot establish whether it is affecting feeding. Assessment should consider tongue function, observed feeding, maternal comfort, milk transfer and the baby's wider clinical picture (NICE, 2017). Where a baby repeatedly falls asleep before feeding effectively, struggles to maintain attachment, has difficulty coordinating sucking and swallowing or continues to gain weight inadequately, further assessment is more important than repeatedly changing breasts in the hope that the problem will resolve. The appropriate feeding strategy should follow the assessment and be reviewed according to the baby's response (Academy of Breastfeeding Medicine, 2022; NICE, 2017). For professionals supporting feeding dyads, documenting the presenting concern, observed feeding behaviour, parental comfort, agreed feeding plan and review arrangements can support continuity of care. This also helps ensure that a technique is reviewed when it is not meeting the baby's needs, rather than continuing without evidence of improvement (Academy of Breastfeeding Medicine, 2022). The role of switch nursing in a wider feeding plan Switch nursing can be a useful technique for encouraging active feeding and providing additional breast stimulation. It may be considered when milk production needs increasing or when a baby becomes less active at the breast before feeding effectively. It can be combined with breast compressions, effective positioning and attachment, breast shaping and expressing where appropriate (Riordan and Wambach, 2016; La Leche League Canada, 2024). However, the aim is not to keep a baby at the breast for as long as possible or to increase the number of switches without considering the outcome. The important questions are whether the baby is transferring milk effectively, receiving adequate nutrition, maintaining hydration and growing as expected (NICE, 2017; Academy of Breastfeeding Medicine, 2022). When weight gain is concerning, weighing provides information about progress, but the feeding plan must address the factors contributing to the concern. Specialist infant-feeding support and appropriate healthcare involvement can help families understand what is happening, protect the baby's health and support milk production where needed. The mother's emotional wellbeing also deserves attention throughout this process (NICE, 2017; World Health Organization, 2022). The most useful feeding strategy is one that meets the baby's nutritional needs, supports the family's feeding goals and is reviewed according to the response of the individual feeding dyad. References Academy of Breastfeeding Medicine (2017) ‘ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017’, Breastfeeding Medicine, 12(3), pp. 188–198. doi: 10.1089/bfm.2017.29038.ajk. Academy of Breastfeeding Medicine (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for birth hospitalization discharge of breastfeeding dyads, revised 2022’, Breastfeeding Medicine, 17(3), pp. 197–206. doi: 10.1089/bfm.2022.29203.aeh. de Carvalho, M., Robertson, S., Merkatz, R. and Klaus, M. (1983) ‘Effect of frequent breastfeeding on early milk production and infant weight gain’, Pediatrics, 72(3), pp. 307–311. Kellams, A., Harrel, C., Omage, S., Gregory, C. and Rosen-Carole, C. (2017) ‘ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017’, Breastfeeding Medicine, 12(3), pp. 188–198. doi: 10.1089/bfm.2017.29038.ajk. Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A. and Hartmann, P.E. (2006) ‘Volume and frequency of breastfeedings and fat content of breast milk throughout the day’, Pediatrics, 117(3), pp. e387–e395. doi: 10.1542/peds.2005-1417. La Leche League Canada (2024) Breast compressions and switch nursing. Available at: https://www.lllc.ca/breast-compressions-and-switch-nursing. La Leche League Great Britain (n.d.) Relactation and induced lactation. Available at: https://laleche.org.uk/relactation-induced-lactation/. National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. Available at: https://www.nice.org.uk/guidance/ng75. Riordan, J. and Wambach, K. (2016) Breastfeeding and human lactation. 5th edn. Burlington, MA: Jones & Bartlett Learning. University Hospitals Sussex NHS Foundation Trust (n.d.) Helping your breastfed baby to get all the milk they need. Available at: https://www.uhsussex.nhs.uk/resources/helping-your-breastfed-baby-to-get-all-the-milk-they-need-2/. World Health Organization (2022) WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240045989. World Health Organization (2022) WHO guide for integration of perinatal mental health in maternal and child health services. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240057142.

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

Tongue tone can be relevant to infant feeding because the tongue needs to maintain an appropriate level of muscular activity while also making coordinated movements for sucking, swallowing and breathing. Effective oral feeding depends on the interaction of these movements rather than on the action of a single muscle, with the tongue working alongside the lips, jaw, palate, pharynx and respiratory system as the infant develops increasingly coordinated feeding skills (Lau, 2015; Lau, 2016; Watson Genna and Sandora, 2017). When reduced tongue tone is observed in an infant, the finding therefore needs to be considered in relation to what the tongue is able to do during feeding. Tongue tone, tongue strength, tongue movement and tongue coordination describe different aspects of function and should not be used interchangeably, particularly when trying to understand why an infant may be experiencing difficulty with feeding. What is tongue tone? Muscle tone is generally described as the tension present within a muscle at rest and the resistance encountered when a muscle is passively stretched. It is influenced by the nervous system and the interaction between neural input and the muscular system, rather than being a simple measure of muscle strength (Ganguly et al., 2021). Muscle tone and muscle strength are consequently different physiological concepts. Strength concerns the force a muscle can voluntarily or reflexively generate, whereas tone relates to the muscle's state and resistance to passive movement. Reduced tone does not therefore necessarily mean that a muscle is weak, just as apparently normal tone does not establish that a muscle has normal functional strength (Ganguly et al., 2021). The tongue is a particularly complex muscular organ. It contains intrinsic and extrinsic muscles arranged in a three-dimensional network, with extensive neuromuscular innervation that permits changes in both tongue shape and position (Mu and Sanders, 2010; Sakamoto, 2018). The intrinsic muscles are contained within the tongue and contribute substantially to changes in its shape, while the extrinsic muscles connect the tongue with surrounding structures and contribute to its movement and positioning (Mu and Sanders, 2010; Sakamoto, 2018). For this reason, when reduced tongue tone is described clinically, it is useful to consider what has actually been observed. An infant may demonstrate reduced resistance to passive movement, reduced ability to maintain a particular tongue position, limited elevation or protrusion, reduced endurance, or difficulty coordinating the tongue with the other movements required for feeding. These findings may have different underlying explanations and should not automatically be interpreted as evidence of a neurological or neuromuscular disorder. Reduced tongue tone (hypotonia) Reduced muscle tone, or hypotonia, describes a reduction in the resistance normally encountered during passive movement and may arise from abnormalities affecting the central or peripheral nervous system, neuromuscular junction or muscle itself (Ganguly et al., 2021). In an infant presenting with feeding difficulty, however, an apparently low-tone tongue does not necessarily indicate generalised hypotonia, as oral feeding skills develop through maturation and experience and differences in oral motor coordination can affect feeding without representing a primary neurological or muscular disorder (Lau, 2016). Where reduced tongue tone is observed, consideration can therefore be given to how the tongue behaves during both rest and active feeding, including its ability to maintain position, elevate, protrude, retract and coordinate with the jaw and other structures involved in sucking and swallowing. Reduced tone may affect the tongue's ability to sustain the movements required for effective feeding, although the clinical significance depends upon the infant's overall functional presentation rather than the appearance of the tongue alone (Watson Genna, 2017). Increased tongue tone (hypertonia) Increased muscle tone, or hypertonia, represents the opposite alteration in tone and describes an abnormal increase in resistance to movement. Hypertonia can arise through a number of neurological mechanisms and should not simply be equated with having a strong or highly active muscle (Ganguly et al., 2021). In the tongue, increased tone may influence the infant's ability to make smooth, graded and appropriately coordinated movements during feeding. As with reduced tone, however, the observation of increased resistance or tension does not by itself establish a diagnosis of hypertonia, and its significance needs to be considered alongside the infant's neurological, oral and feeding presentation. Considering hypotonia and hypertonia together is useful because both represent alterations in muscle tone, but they can affect movement in different ways. Neither finding should be interpreted in isolation from function, and neither should automatically be assumed to explain a feeding difficulty without considering the wider clinical picture. Development and anatomy of the tongue The tongue begins developing during the fourth to fifth weeks of gestation from structures associated with the pharyngeal arches, while the muscular component develops predominantly from occipital somites and subsequently receives its principal motor supply from the hypoglossal nerve (Mu and Sanders, 2010; Thomas et al., 2024). Its anatomy is consequently complex, with intrinsic and extrinsic muscles arranged throughout the tongue rather than functioning as a simple set of isolated muscles. The tongue's neuromuscular organisation allows it to change shape and position rapidly and with considerable precision, which is important for functions including swallowing, respiration and feeding (Mu and Sanders, 2010; Sakamoto, 2018). This developmental and anatomical complexity is relevant when considering tongue tone because an infant's ability to use the tongue effectively depends not simply upon the presence of muscle tissue, but upon the interaction between muscular contraction, neural control, sensory information and the surrounding oral structures. Tongue function during infant feeding Infant feeding involves coordinated patterns of sucking, swallowing and breathing. Sucking provides the initial mechanism for obtaining milk, while swallowing then moves the milk safely from the oral cavity towards the pharynx, with these processes becoming increasingly coordinated as the infant matures (Lau, 2015; Lau, 2016). Watson Genna and Sandora describe sucking and swallowing as closely integrated processes involving coordinated tongue, jaw and oral movements, with the tongue contributing to milk expression and movement within the oral cavity before and during swallowing (Watson Genna and Sandora, 2017). Swallowing itself comprises oral, pharyngeal and oesophageal phases, with the oral phase involving the tongue's preparation and propulsion of the bolus before the pharyngeal swallow is initiated (Watson Genna and Sandora, 2017). The tongue therefore has an important influence on an infant's ability to manage milk within the mouth and to initiate effective swallowing, rather than its role being limited to attachment or milk removal. Lau (2016) similarly describes infant oral feeding as a developing motor skill that depends upon the maturation and coordination of sucking, swallowing and breathing. A difference in tongue tone or movement may consequently have implications for feeding, but the observation itself does not identify the cause. Feeding ability can be influenced by developmental maturity, gestational age, neurological status, oral anatomy, sensory-motor organisation and the mechanics of the feeding method, making a functional feeding assessment more informative than considering tongue tone in isolation (Lau, 2016; Watson Genna and Sandora, 2017). Resting tongue posture The tongue remains under neuromuscular control when an infant is not actively feeding, and its resting position is influenced by the surrounding oral and craniofacial structures as well as by muscular activity (Mu and Sanders, 2010; Sakamoto, 2018). An infant may therefore demonstrate a resting tongue posture that appears low, forward, retracted or otherwise different from that expected for effective oral function. Resting position alone, however, does not establish whether tongue tone is reduced because the position of the tongue results from the interaction between muscular activity, anatomy, sensory and motor control and the surrounding structures. Considering resting posture alongside active movement and feeding function can therefore provide a more meaningful picture than treating a particular resting position as diagnostic in itself. What can contribute to altered tongue tone or function? Altered tongue tone does not have a single cause. Where genuine hypotonia or hypertonia is present, the underlying mechanisms may involve the central or peripheral nervous system, neuromuscular junction or muscle itself, with the clinical presentation depending upon the underlying condition (Ganguly et al., 2021). In an infant presenting with feeding difficulty, however, an apparently low-tone or high-tone tongue does not necessarily indicate a primary neurological or muscular disorder. Infant oral feeding skills develop through maturation and experience, and differences in coordination or oral motor organisation can affect feeding without representing pathological alteration of muscle tone (Lau, 2016). Other factors may therefore need consideration, including prematurity or developmental immaturity, neurological or neuromuscular conditions where clinically indicated, differences in oral anatomy, sensory-motor coordination, fatigue and mechanical restriction of tongue movement. These possibilities should be distinguished from one another rather than being grouped together simply because the tongue appears to have altered tone or movement. A restrictive lingual frenulum is one anatomical factor that may be relevant when there is demonstrable limitation of tongue movement. Tongue function exercises Where reduced tongue tone or impaired tongue function has been identified as contributing to feeding difficulty, targeted tongue exercises may form part of a conservative management approach. The purpose is not simply to exercise the tongue for its own sake, but to encourage more effective muscular recruitment, movement, coordination and endurance in relation to the functional demands of feeding. Watson Genna's work on supporting infant sucking skills includes consideration of tongue exercises within the management of infants with anatomical or functional factors affecting sucking skills, including ankyloglossia (Watson Genna, 2017). The aim of this approach is to improve the infant's ability to use the tongue functionally for feeding, including the movements involved in sucking and swallowing, rather than presenting exercises as a universal treatment for feeding difficulties. Their use is therefore best considered in relation to the findings of the individual feeding assessment and the particular functional difficulty being addressed. Conservative management may be appropriate where the clinical findings indicate that supporting tongue function is a reasonable first approach, including situations in which there is reduced tongue tone or movement but no indication that a surgical procedure is required. Where a restrictive frenulum is also present, conservative management can provide an opportunity to assess whether functional improvement can be achieved without division, while recognising that some infants may continue to have a mechanically restricted tongue despite supportive measures. Tongue-tie, tongue tone and feeding Ankyloglossia refers to a congenital restriction of tongue movement associated with the lingual frenulum, although there remains variation in how ankyloglossia is defined and assessed (Thomas et al., 2024; LeFort et al., 2021). The presence of a lingual frenulum variation does not by itself establish that feeding will be affected, and the American Academy of Pediatrics emphasises the importance of identifying a functional feeding problem rather than diagnosing symptomatic ankyloglossia from anatomy alone (Thomas et al., 2024). A restrictive frenulum can mechanically limit aspects of tongue movement, including elevation and extension, and this provides a plausible explanation for why some infants with ankyloglossia may experience difficulty using the tongue effectively during feeding (Thomas et al., 2024). If movement is restricted, the way in which the tongue is positioned and recruited during sucking and swallowing may also be altered, and this may be observed clinically as reduced functional tongue tone or reduced functional tongue movement. The available evidence does not, however, establish a direct causal pathway in which ankyloglossia causes reduced tongue muscle tone, nor does it establish that division of the frenulum directly increases tongue muscle tone. The more established relationship concerns mechanical restriction of tongue movement and its potential effect on feeding function, while the question of how restriction may influence muscular recruitment and tone requires further research. This distinction is important when considering frenulum division because the evidence for the procedure is primarily concerned with feeding outcomes rather than measurement of tongue muscle tone. The 2017 Cochrane review found that frenotomy reduced maternal nipple pain in the short term but did not consistently demonstrate improvement in objective measures of infant breastfeeding, with the certainty of the evidence limited by small studies and methodological weaknesses (O'Shea et al., 2017). More recent evidence has added to the available literature but has not removed this uncertainty: a 2026 umbrella review identified conflicting findings across systematic reviews, while a 2026 systematic review and meta-analysis of 47 studies found improvements in some feeding-related outcomes but concluded that the overall certainty of evidence supporting frenotomy was very low (da Silva et al., 2026; Dhar et al., 2026). The current evidence therefore supports consideration of frenotomy where a restrictive frenulum is associated with documented functional impairment and conservative measures have not resolved the difficulty, but it does not support presenting division as a treatment for low tongue muscle tone itself. A functional feeding assessment remains important because feeding difficulties can have multiple contributing factors and because the presence of a restrictive frenulum does not necessarily mean that it is the cause of the observed difficulty (Thomas et al., 2024; Dhar et al., 2026). Looking at the whole feeding mechanism Reduced tongue tone is best regarded as one clinical finding within the wider assessment of oral feeding rather than as an explanation for feeding difficulty in itself. The tongue is a complex muscular and sensory structure, and effective feeding depends upon its interaction with the jaw, lips, palate, pharynx and respiratory system as well as upon developing neurological control (Lau, 2016; Mu and Sanders, 2010; Watson Genna and Sandora, 2017). When altered tongue tone is observed, it is therefore useful to consider what movements are affected, whether the finding is consistent across different activities, how it relates to sucking and swallowing, and whether there is an identifiable developmental, neurological, muscular, anatomical or mechanical contributor. Where a restrictive lingual frenulum is present, its significance needs to be considered in relation to demonstrable tongue function rather than anatomy alone. Tongue exercises may provide one conservative management option where reduced tone or function has been identified, with the aim of supporting more effective tongue movement and feeding. Where mechanical restriction remains significant despite appropriate conservative management, frenulum division may be considered when the clinical assessment indicates that the restriction is contributing to the feeding difficulty. Neither approach should be presented as a universal answer to low tongue tone, because the underlying cause and functional presentation will differ between infants. The distinction between anatomy, tone, strength, movement and function is therefore important when considering an infant with feeding difficulty. An evidence-based assessment allows these findings to be considered individually and then brought together to establish the most appropriate explanation and management approach for the feeding dyad. References da Silva, B.V., Barollo, A.V., Sá, N.N.L., Oliveira, L.B. and Sanglard, L.F. (2026) ‘Lingual Frenotomy in Breastfeeding Infants: An Umbrella Review’, International Journal of Paediatric Dentistry, 36(1), pp. 90–104. doi: 10.1111/ipd.70031. Dhar, V., Marghalani, A.A., Amini, H., Brickhouse, T., Caffrey, E., Jayaraman, J., Keels, M.A., Messner, A., Patterson, K.K., Raol, N., Shrestha, P., Stark, C.M., Susarla, H.K. and Thomas, J. (2026) ‘Frenotomy for Ankyloglossia Associated With Feeding Challenges in Infants: Effectiveness, Technique, and Safety—A Systematic Review and Meta-Analysis, Part 2’, Pediatric Dentistry, 48(2), pp. 33E–68E. Ganguly, J., Kulshreshtha, D., Almotiri, M. and Jog, M. (2021) ‘Muscle Tone Physiology and Abnormalities’, Toxins, 13(4), 282. doi: 10.3390/toxins13040282. Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. doi: 10.1159/000381361. Lau, C. (2016) ‘Development of infant oral feeding skills: what do we know?’, The American Journal of Clinical Nutrition, 103(2), pp. 616S–621S. doi: 10.3945/ajcn.115.109603. LeFort, Y., Evans, A., Arsenault, A., Mazzocchi, A., Dempsey, E., Cormier, C., Cuthbertson, L., Francis, D.O. et al. (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. doi: 10.1089/bfm.2021.29179.ylf. Mu, L. and Sanders, I. (2010) ‘Human tongue neuroanatomy: nerve supply and motor endplates’, Clinical Anatomy, 23(7), pp. 777–791. doi: 10.1002/ca.21011. O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 2017(3), CD011065. doi: 10.1002/14651858.CD011065.pub2. Sakamoto, Y. (2018) ‘Structural arrangement of the intrinsic muscles of the tongue and their relationships with the extrinsic muscles’, Surgical and Radiologic Anatomy, 40(6), pp. 681–688. doi: 10.1007/s00276-018-1993-5. Thomas, J., Bunik, M., Holmes, A., Keels, M.A., Poindexter, B., Meyer, A., Gilliland, A. et al. (2024) ‘Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report’, Pediatrics, 154(2), e2024067605. doi: 10.1542/peds.2024-067605. Watson Genna, C. (ed.) (2017) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning. Watson Genna, C. and Sandora, L. (2017) ‘Breastfeeding: normal sucking and swallowing’, in Watson Genna, C. (ed.) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning, pp. 1–42.

Vitamin K is routinely offered to newborn babies in the UK to reduce the risk of vitamin K deficiency bleeding (VKDB), a rare but potentially serious bleeding disorder. For many families, the decision about vitamin K is made shortly before or after birth, at a time when there may already be many new things to consider. Some families accept vitamin K by injection, some choose an oral course, and some decide not to give vitamin K. Families should be given clear information about what vitamin K does, why newborn babies have relatively low levels, what the different routes of administration involve and what options may remain available if the initial decision changes. Vitamin K is not a treatment for feeding difficulties or tongue-tie. Its relevance to feeding is therefore limited, although its status can become important when an invasive procedure such as frenulotomy is being considered because bleeding is a recognised potential complication of the procedure. What is vitamin K? Vitamin K is a fat-soluble vitamin with several functions within the body. One of its most important roles is in normal blood clotting. Vitamin K is required by the liver to produce several vitamin-K-dependent clotting factors, including factors II, VII, IX and X, which are necessary for the blood to form an effective clot. Newborn babies begin life with relatively low vitamin K stores. Only a small amount of vitamin K crosses the placenta, and human milk naturally contains relatively little vitamin K. This means that a newborn has limited reserves during a period when the systems involved in maintaining adequate vitamin K levels are still developing. As infancy progresses, the baby's sources and stores of vitamin K increase. This is a gradual process rather than a particular point at which the risk suddenly disappears, which is one reason why vitamin K deficiency can remain relevant beyond the first few days of life (NICE, 2026a). Vitamin K deficiency matters because insufficient vitamin K can reduce the liver's ability to produce adequate amounts of the clotting factors needed for normal haemostasis. In a baby with significant deficiency, bleeding can therefore occur without an obvious injury to explain it. Why are newborn babies offered vitamin K? Vitamin K deficiency bleeding, or VKDB, is uncommon, but it can be serious and, in some cases, life-threatening. It can occur during the first hours and days after birth or later during infancy. VKDB is generally described according to when it occurs. Early VKDB occurs within the first 24 hours of life, classical VKDB generally occurs during the first week, and late VKDB occurs from around one week until several months of age. Late VKDB is particularly concerning because bleeding can occur internally, including within the brain, and there may not always be an obvious warning before significant illness develops (NICE, 2026a). The purpose of vitamin K prophylaxis is therefore prevention. It does not treat an existing feeding problem, tongue-tie or other newborn condition; it reduces the likelihood that a baby will develop bleeding as a result of vitamin K deficiency. NICE recommends that vitamin K prophylaxis is offered to newborn babies because vitamin K deficiency bleeding, although rare, can have serious consequences (NICE, 2026a). How is vitamin K administered? In the UK, vitamin K can be administered by intramuscular injection or orally. NICE recommends that parents should be offered vitamin K prophylaxis and explains that intramuscular administration is the most effective method. Where parents do not want their baby to receive an injection, oral vitamin K should be offered as an alternative (NICE, 2026a). Vitamin K by injection The intramuscular injection is generally given into the baby's thigh. A single dose provides a reliable source of vitamin K during the period when the baby is most vulnerable to deficiency. As with any injection, there can be brief discomfort and local effects such as soreness or bruising. These considerations can form part of the discussion with families when they are deciding which route they prefer. Vitamin K by mouth Oral vitamin K provides an alternative for families who do not want their baby to receive an intramuscular injection. The important difference is that oral administration involves a course of doses rather than relying on a single injection. The exact preparation and dosing schedule should be provided by the maternity or neonatal service and followed according to the manufacturer's instructions. NICE advises that families choosing oral vitamin K should understand that several doses may be required, including doses after the baby has left hospital (NICE, 2026a). This means that an oral course is dependent on the recommended doses actually being received. If a dose is missed, vomited or otherwise not given, the family should seek advice from the healthcare professional responsible for the baby's care about what should happen next rather than assuming that the course remains complete. The route of administration is also considered in the context of the individual baby. Prematurity, illness and other clinical circumstances may affect which option is most appropriate. What if a family initially declines vitamin K? Parents and legal caregivers should be able to make an informed decision about vitamin K after being given appropriate information about its purpose, benefits and limitations. A decision to decline vitamin K should not prevent a family from accessing other healthcare or from asking questions and revisiting the decision. Some families may initially decline vitamin K but later decide that they would like their baby to receive it. In that situation, the appropriate next step is to contact the maternity service, neonatal team, GP, health visitor or another appropriate NHS healthcare professional so that the baby's age, health, previous doses and the available preparation can be taken into account. There is not one universal catch-up approach that can simply be applied to every baby who initially declined prophylaxis. The appropriate regimen depends on the individual circumstances, so families should obtain advice from the service responsible for the baby's care rather than relying on a general schedule found online. This is an area where informed choice is particularly important. Dr Sara Wickham has written extensively about vitamin K, including the evidence surrounding prophylaxis, the distinction between relative and absolute risk, and what families who decline vitamin K should know (Wickham, 2026a; Wickham, 2026b). Her work provides additional discussion for families who want to explore the evidence and uncertainties surrounding the decision. What if an oral course was started but not completed? An incomplete oral course needs to be distinguished from a completed course of oral prophylaxis. If one or more doses have been missed, the appropriate response depends on the baby's age, the preparation used, which doses were received and the baby's wider health circumstances. Families should therefore contact the relevant maternity, neonatal or medical service for advice. This distinction can become particularly important if the baby subsequently requires an invasive procedure. Knowing that “vitamin K was given” is not necessarily enough information; the route, timing and completion of an oral course may all be relevant when considering the baby's current circumstances. Vitamin K and clinical procedures Vitamin K status can become particularly relevant when an infant is being considered for an invasive or surgical procedure. Frenulotomy involves division of the lingual frenulum and is a regulated surgical procedure in its own right. Although the area being divided is small, tissue containing blood vessels is being cut and bleeding is a recognised potential complication. A small amount of bleeding may occur following frenulotomy and will generally be managed as part of the procedure and its immediate aftercare. More significant bleeding is uncommon, but it is one of the risks that should be considered when assessing whether a procedure is appropriate. For this reason, vitamin K status may form part of the clinical assessment before an elective procedure. This may include establishing whether vitamin K was given, whether it was administered intramuscularly or orally, whether an oral course was completed and whether there are other factors that could affect bleeding risk. The absence of vitamin K prophylaxis does not automatically mean that an elective procedure can never take place. Equally, a clinician or service may determine that it is not appropriate to proceed until the individual bleeding risk has been assessed more fully. This is an important distinction. A decision to postpone or decline an elective procedure because the bleeding risk cannot be adequately assessed is a clinical safety decision. It should not be presented as a judgement about the family for having made a particular decision regarding vitamin K. What else might affect bleeding risk? Vitamin K status is only one part of an assessment. A baby's medical history may identify additional circumstances that warrant consideration before an invasive procedure. These can include prematurity, significant illness, a known liver condition, conditions affecting bile flow or vitamin absorption, unexplained or unusual bruising or bleeding, or a family history of a diagnosed bleeding disorder. The liver is particularly relevant because it is responsible for producing the vitamin-K-dependent clotting factors. Conditions affecting liver function can therefore have implications for haemostasis independently of whether vitamin K prophylaxis was given. Conditions affecting bile flow can also be relevant because vitamin K is fat-soluble and its absorption depends partly on normal fat digestion and bile delivery to the intestine. Persistent pale or unusually light stools, particularly when accompanied by jaundice or dark urine, require medical assessment because they can be signs of cholestasis or another underlying condition. This is not simply a question of whether the baby has “bowel problems”, and such symptoms should not be attributed to vitamin K deficiency without appropriate assessment. Where there is uncertainty about a baby's bleeding risk, medical review may be appropriate. In some circumstances, blood tests assessing clotting may form part of that assessment. The decision to investigate should be based on the individual baby and the clinical question rather than automatically applying the same testing to every baby who has not received vitamin K. A normal screening result also does not exclude every possible bleeding disorder, so investigations should be interpreted alongside the baby's history and clinical presentation. What should families know if vitamin K was declined? Families who have decided not to give vitamin K should know what symptoms require medical attention, because the absence of prophylaxis means the baby remains at risk of VKDB. Unexplained bleeding should be medically assessed rather than assumed to be part of normal newborn care. This may include persistent bleeding from the umbilical area, bleeding from the nose or mouth, blood in the urine, blood in vomit or stools, or unusual bruising. More serious symptoms can include marked pallor, unusual sleepiness, difficulty waking, seizures or other signs that the baby is acutely unwell. Internal bleeding may not always be immediately visible, which is one reason why significant changes in a baby's behaviour or condition should not be dismissed. Families should seek urgent medical attention if their baby appears seriously unwell or develops unexplained bleeding. Vitamin K and feeding Vitamin K is not a treatment for breastfeeding difficulties, bottle-feeding difficulties, milk transfer problems or tongue-tie. There is a difference in vitamin K content between human milk and infant formula, with formula containing added vitamin K. This does not mean that one method of feeding should be considered preferable on the basis of vitamin K. Vitamin K prophylaxis is offered because newborn babies have relatively low vitamin K stores and can develop VKDB irrespective of how their feeding develops. Feeding difficulties should therefore be assessed on their own merits. A baby who is struggling with breastfeeding, bottle feeding, expressing or combination feeding may have a range of contributing factors, and vitamin K status should not be used as an explanation for feeding symptoms. Similarly, vitamin K does not determine whether a baby has a tongue-tie or whether frenulotomy is clinically appropriate. Decisions about tongue-tie should consider function, feeding history, observed feeding where appropriate, growth, comfort, previous support and the individual circumstances of the feeding dyad. Vitamin K, choice and individual assessment The decision about vitamin K belongs within the wider process of informed consent and individualised newborn care. For some families, the decision will be straightforward. Others may want to understand more about the evidence, the difference between injection and oral administration, or what declining prophylaxis means. A family may also make one decision immediately after birth and reconsider it later as circumstances or understanding change. Respecting informed choice does not remove the responsibility of healthcare professionals to explain relevant risks, nor does it require a practitioner undertaking an elective procedure to ignore an unresolved bleeding risk. Where vitamin K has been declined, where an oral course is incomplete, or where records cannot confirm what was administered, the appropriate response before an elective procedure may therefore be an individual assessment of the baby's bleeding risk. Depending on the circumstances, this may involve obtaining further clinical information, seeking medical advice or considering investigations such as coagulation screening. For frenulotomy, this forms only one part of the overall assessment. The reason for considering the procedure, the infant's oral function, feeding circumstances, potential benefits and limitations, alternatives and the family's informed decision all remain relevant. Vitamin K is one part of newborn care, but understanding why it is offered, how it can be administered and what happens when prophylaxis is declined or incomplete allows families and healthcare professionals to approach the subject with greater clarity and without unnecessary assumptions. References National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE. National Institute for Health and Care Excellence (NICE) (2026a) Postnatal care. NICE guideline NG194. London: NICE. National Institute for Health and Care Excellence (NICE) (2026b) Intrapartum care. NICE guideline NG235. London: NICE. O'Shea, J.E., Foster, J.P., O'Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) 'Frenotomy for tongue-tie in newborn infants', Cochrane Database of Systematic Reviews, 3, CD011065. Puckett, R.M. and Offringa, M. (2000) 'Prophylactic vitamin K for vitamin K deficiency bleeding in neonates', Cochrane Database of Systematic Reviews, 4, CD002776. Watson, R., McNinch, A., Gillbertson, C. et al. (2011) 'Guidelines on the administration of vitamin K to newborn infants', British Journal of Haematology, 154(1), pp. 8–17. Wickham, S. (2026a) 'Five things parents should know if they decide to decline vitamin K'. Sara Wickham. Wickham, S. (2026b) 'Vitamin K: evidence, risk and informed choice'. Sara Wickham.

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

When milk production appears lower than expected, it is easy to start looking for something that might increase it. Galactogogues are medicines, herbs or other substances used with the intention of increasing milk production, but the evidence for their effectiveness is mixed. For some families, a galactogogue may have a place within an individualised feeding plan. For others, it may add cost, side effects or complexity without addressing the reason milk production appears to be low. Before considering one, it is useful to establish whether milk production is actually lower than expected and, if so, what may be contributing to this. What are galactogogues? Galactogogues are substances used with the intention of increasing milk production. They include prescription medicines as well as herbal and food-based products. Medicines that have been studied in lactation include domperidone and metoclopramide. Herbal and food-based products marketed for milk production may contain ingredients such as fenugreek, fennel, milk thistle, moringa or shatavari, either individually or in combination. The existence of a product marketed as a galactogogue does not establish that it works. The more useful questions are whether it has been shown to increase milk production, in which circumstances, by how much, and whether any potential benefit outweighs its risks (Brodribb, 2018; Foong et al., 2020). Is milk production actually low? One of the first questions is whether there is evidence of low milk production rather than a change in how the breasts feel or how feeding looks. Milk production changes considerably during the early weeks after birth. Initially, lactation is largely under endocrine control, with hormonal changes following birth playing an important role in establishing milk production. As lactation becomes established, control becomes increasingly autocrine. Milk production is then more closely regulated within the breast according to milk removal and local mechanisms within the mammary gland (De Coopman, 1993; Knight, Peaker and Wilde, 1998; Wilde et al., 1998). As this transition occurs, the initial fullness of the breasts commonly reduces and the breasts may feel much softer between feeds. This is an expected change in established lactation. Soft breasts at this stage do not, by themselves, mean that milk production has fallen or that there is not enough milk. After the early weeks, an infant's growth, hydration and overall feeding picture are much more useful indicators of milk intake than breast fullness alone. NHS guidance identifies weight gain, wet nappies, swallowing during feeds and other aspects of feeding as useful indicators that an infant is receiving enough milk (NHS, 2026). Frequent feeding, periods when an infant is unsettled or obtaining a small volume when expressing can also be interpreted as signs of low supply when they may have other explanations. Expressed milk volume is not a direct measurement of total milk production. Pump fit and settings, timing, breast fullness, milk ejection and an individual's response to expressing can all affect the amount collected during a particular session. My articles Increasing Breast Milk Production and How to Express Breastmilk look at milk production and expressing in more detail. A proper assessment considers the wider feeding picture, including infant growth and hydration, feeding frequency, milk transfer, maternal health, birth and postpartum history and expressing practices where relevant (Brodribb, 2018; Foong et al., 2020). Positioning and attachment can also affect how comfortably and effectively milk is removed. My articles Breastfeeding latch and positioning and How to Improve Infant Latch: Practical Breastfeeding Support explore these areas further. If expressing is part of the feeding plan, pump fit can also be relevant. Breast Pump Flange Fitting: Finding What Works for You considers how flange fit can affect comfort and milk removal. Infant oral function may also be relevant in some feeding situations, but an anatomical finding does not, by itself, establish that it is the cause of reduced milk transfer or milk production. Function needs to be considered alongside the whole feeding picture. My article Breastfeeding problems caused by tongue-tie? explores why feeding difficulties need to be considered more broadly than the appearance of the lingual frenulum. What does the evidence actually show? The evidence for galactogogues is limited and does not support a universal recommendation for their use. A Cochrane review of oral galactogogues in mothers of healthy term infants included 41 studies involving 3,005 mothers. The studies varied considerably in the interventions used, participant characteristics and outcome measures. There was low-certainty evidence that pharmacological galactogogues may increase milk volume, while evidence for natural galactogogues was very uncertain (Foong et al., 2020). This does not mean that an individual cannot experience an increase in milk production after using a galactogogue. It means that the available evidence does not allow us to predict reliably who will benefit, how much benefit can be expected or whether an observed change was caused by the galactogogue itself. The Academy of Breastfeeding Medicine advises that potentially modifiable causes of low milk production are assessed before considering a galactogogue, rather than using medication or supplements as the first response to the concern (Brodribb, 2018). Does the preparation matter? Yes. A herb is not a single standardised dose simply because it has the same name on the packet. A tea, capsule, powder, tincture, extract, cookie or other food containing an herb can provide very different amounts of its active constituents. A teabag and a concentrated extract are not necessarily equivalent. This means that evidence from a study using one particular preparation cannot automatically be applied to a different commercial product containing the same herb. The same applies to products containing several ingredients. If a study examines a particular combination, its findings cannot automatically be transferred to another tea, supplement or food containing some of the same ingredients. This is one reason the evidence for commercial lactation products can be difficult to interpret. A product may contain an ingredient that has been studied without the product itself having been studied. A randomised controlled trial of commercially available lactation cookies containing oatmeal, brewer's yeast, flaxseed and fenugreek found no significant difference in milk production between the intervention and control cookies. The study also found no significant difference in perceived insufficient milk or breastfeeding self-efficacy (Palacios et al., 2023). The presence of ingredients traditionally or commercially described as galactagogues does not, by itself, establish that a particular food will increase milk production. What about herbal galactogogues? Herbal products are sometimes perceived as a gentler alternative to medicines because they are described as natural. Natural does not necessarily mean effective, free from side effects or suitable for everyone. Fenugreek, fennel, milk thistle, moringa and shatavari are among the herbs that have been studied or used in relation to milk production, but the amount and quality of evidence varies considerably. The Cochrane review found substantial variation between studies and uncertainty around the effects of natural galactogogues (Foong et al., 2020). Herbal products can also cause side effects or interact with medicines. Products may contain several ingredients, and the amount of an active constituent can vary between preparations. There is also a difference between traditional use and evidence of clinical effectiveness. A herb may have been used for generations for a particular purpose without there being good-quality clinical evidence showing that it produces that effect. That does not make traditional knowledge irrelevant. It does mean that it should not be presented as equivalent to evidence from well-designed clinical research. Can herbs reduce milk production too? This is another part of the discussion that is sometimes overlooked. Some herbs and herbal preparations are traditionally used with the intention of reducing milk production, particularly during weaning or when someone is experiencing oversupply. Sage and peppermint are two commonly discussed examples. The evidence for these effects is limited. LactMed reports that sage is traditionally used to reduce lactation and that peppermint has also been used to suppress milk production, but clinical evidence demonstrating these effects in breastfeeding women is lacking. For peppermint, milk-suppressing effects have been demonstrated in vitro and in animals with high doses, but it is not known whether typical human intake would have the same effect (National Library of Medicine, 2025a; 2025b). The important point is that herbal preparations can have different intended effects depending on the herb, preparation and circumstances. “Herbal” does not automatically mean “milk increasing”. If the aim is to reduce or stop breastfeeding, my article Stopping Breastfeeding looks at the gradual changes involved in reducing milk removal and managing the transition. What about domperidone? Domperidone is an anti-sickness medicine that can also increase prolactin and has been used off-label to support milk production. It is not licensed in the UK specifically for increasing milk supply. The Specialist Pharmacy Service suggests that domperidone can be considered for low milk supply after a thorough assessment and once non-medical measures have been tried. Its guidance also notes that most of the evidence comes from mothers expressing milk for preterm infants, with less evidence in mothers feeding healthy term infants (Specialist Pharmacy Service, 2024). Some specialist lactation guidance has described using doses higher than those generally used in current UK practice, including in circumstances such as delayed onset of lactogenesis. These approaches should not be interpreted as general dosing recommendations. Any use of domperidone should be discussed with the prescriber responsible for the individual (Newman, 2005). Cardiac safety also needs to be considered in context. The evidence of increased cardiac risk comes largely from studies in older adults, rather than healthy lactating women. For example, one major study had a mean age of 79.4 years, while evidence in postpartum women remains limited (Johannes et al., 2010; Ou et al., 2021). If domperidone has been used for a period of time, stopping also needs consideration. Some lactation guidance describes gradual reduction rather than simply stopping, particularly after longer-term use. Any change in treatment should be planned with the prescriber rather than made independently (Newman, 2005; The Breastfeeding Network, 2026). What about metoclopramide? Metoclopramide has also been studied as a galactogogue, but evidence of benefit is inconsistent. A systematic review and meta-analysis of eight trials involving 342 lactating women found that metoclopramide increased prolactin concentrations but did not increase milk volume compared with control treatment (Nik Hazlina Nik Hussain et al., 2021). Metoclopramide can also cause adverse effects, including neurological effects and psychological side effects. The Academy of Breastfeeding Medicine therefore advises consideration of potential adverse effects, contraindications and interactions before a galactogogue is used (Brodribb, 2018). The wider evidence does not establish that increasing prolactin will necessarily produce a clinically meaningful increase in milk production for everyone. Milk production is influenced by milk removal as well as hormonal responses, so a higher prolactin level is not, by itself, a guarantee of more milk (Specialist Pharmacy Service, 2024). Why assessment comes before a galactogogue A galactogogue cannot reliably compensate for milk that is not being removed effectively. If milk removal is being limited by ineffective milk transfer, infrequent milk removal, pain, unsuitable expressing equipment or another modifiable factor, addressing that issue may be more important than adding a product (Brodribb, 2018; Foong et al., 2020). For some feeding dyads, positioning and attachment may be relevant. For others, the issue may involve milk transfer, infant oral function, maternal health, breast surgery, medication, hormonal factors or the way expressing is being used. My article When feeding doesn't feel right: Looking beyond tongue-tie considers some of the wider factors that can contribute to feeding difficulties. If the concern is expressed milk volume, it is also worth considering whether the pump, flange fit, expressing frequency and reason for expressing have been assessed before assuming that milk production itself is low. More expressing is not automatically better. If an infant is already removing milk effectively, repeatedly adding extra pumping sessions can sometimes create an oversupply rather than solve the original concern. My article How to Express Breastmilk discusses the different reasons for expressing and why the approach needs to reflect what someone is trying to achieve. How might a proportionate decision be made? If a galactogogue is being considered, the starting point is not necessarily which product to choose. It is what the family is hoping to achieve. The goal might be to increase direct feeding, increase expressed milk, make combination feeding more sustainable or reduce the need for supplementation. It is then useful to consider: Is milk production actually lower than expected? Is milk being removed frequently and effectively? Are there maternal or infant factors affecting milk production or transfer? Are positioning, attachment or expressing practices contributing? Is there a medical reason for reduced production that needs assessment? What evidence supports the proposed galactogogue? What preparation is actually being considered? Could any other medicines, herbs or supplements be affecting milk production? How will any benefit be assessed? When will the plan be reviewed? What will happen if there is no meaningful benefit? For some families, useful measures may include infant growth and hydration. For someone expressing, changes in milk volume over a defined period may be useful. For others, the most important outcome may be a feeding plan that is more comfortable or sustainable. A defined review is particularly useful. If something is being used with the intention of increasing milk production, there should be a point at which its effect is considered rather than continuing indefinitely without evidence of benefit. There is no single right response to concerns about milk supply Concerns about milk production can be difficult, particularly when feeding has already involved pain, supplementation, expressing or previous challenges. Using a galactogogue does not mean that someone has failed to feed their baby, and choosing not to use one does not mean that they have failed to try hard enough. The evidence supports a measured approach: establish what is happening with milk production and milk transfer, consider modifiable factors, understand the evidence and potential risks associated with any proposed galactogogue, and agree how the outcome will be reviewed. If there are concerns about milk production, feeding or milk transfer, an individual assessment can help identify what may be contributing. This may include support from an appropriately qualified infant feeding specialist, such as an IBCLC, alongside medical assessment where indicated. My article When feeding doesn't feel right: Looking beyond tongue-tie considers the wider feeding picture, while Breastfeeding latch and positioning, How to Improve Infant Latch: Practical Breastfeeding Support, How to Express Breastmilk and Breast Pump Flange Fitting: Finding What Works for You explore specific areas in more detail. Sometimes a galactogogue may have a place. In other circumstances, the more useful intervention may be addressing milk removal, feeding technique, expressing equipment or an underlying maternal or infant factor — or establishing that milk production is not actually lower than expected. References Brodribb, W. (2018) ‘ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018’, Breastfeeding Medicine, 13(5), pp. 307–314. doi: 10.1089/bfm.2018.29092.wjb. De Coopman, J. (1993) ‘Breastfeeding after pituitary resection: support for a theory of autocrine control of milk supply?’, Journal of Human Lactation, 9(1), pp. 35–40. doi: 10.1177/089033449300900129. Foong, S.C., Tan, M.L., Foong, W.C., Marasco, L.A., Ho, J.J. and Ong, J.H. (2020) ‘Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants’, Cochrane Database of Systematic Reviews, 2020(5), CD011505. doi: 10.1002/14651858.CD011505.pub2. Johannes, C.B., Varas-Lorenzo, C., McQuay, L.J., Midkiff, K.D. and Fife, D. (2010) ‘Risk of serious ventricular arrhythmia and sudden cardiac death in a cohort of users of domperidone: a nested case-control study’, Pharmacoepidemiology and Drug Safety, 19(9), pp. 881–888. doi: 10.1002/pds.2016. Knight, C.H., Peaker, M. and Wilde, C.J. (1998) ‘Local control of mammary development and function’, Reviews of Reproduction, 3(2), pp. 104–112. doi: 10.1530/ror.0.0030104. National Library of Medicine (2025a) ‘Peppermint’, Drugs and Lactation Database (LactMed®). Bethesda, MD: National Institute of Child Health and Human Development. Last revision 15 June 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501851/ National Library of Medicine (2025b) ‘Sage’, Drugs and Lactation Database (LactMed®). Bethesda, MD: National Institute of Child Health and Human Development. Last revision 15 July 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501816/ Newman, J. (2005) ‘Domperidone’, Handout #19a, January 2005. Available at: https://breastfeedingmadesimple.com/wp-content/uploads/2016/02/newman_Domperidone1-January2005.pdf Nik Hazlina Nik Hussain, N.H., Mohd Noor, N., Ismail, S.B., Zainuddin, N.A. and Sulaiman, Z. (2021) ‘Metoclopramide for milk production in lactating women: a systematic review and meta-analysis’, Korean Journal of Family Medicine, 42(6), pp. 453–463. doi: 10.4082/kjfm.20.0238. NHS (2026) ‘Breastfeeding: is my baby getting enough milk?’, NHS. Page last reviewed 30 April 2026. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding-problems/enough-milk/ Ou, L.B., Moriello, C., Douros, A. and Filion, K.B. (2021) ‘Domperidone and the risks of sudden cardiac death and ventricular arrhythmia: a systematic review and meta-analysis of observational studies’, British Journal of Clinical Pharmacology, 87(10), pp. 3649–3658. doi: 10.1111/bcp.14737. Palacios, A.M., Cardel, M.I., Parker, E., Dickinson, S., Houin, V.R., Young, B. and Allison, D.B. (2023) ‘Effectiveness of lactation cookies on human milk production rates: a randomized controlled trial’, The American Journal of Clinical Nutrition, 117(5), pp. 1035–1042. doi: 10.1016/j.ajcnut.2023.03.010. Specialist Pharmacy Service (2024) ‘Using domperidone for low milk supply’. Published 21 June 2024. Available at: https://www.sps.nhs.uk/articles/using-domperidone-for-low-milk-supply/ The Breastfeeding Network (2026) ‘Domperidone and breastfeeding’, Drugs in Breastmilk Information. Last full review September 2019; last amended May 2026. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/domperidone/ Wilde, C.J., Addey, C.V., Bryson, J.M., Finch, L.M., Knight, C.H. and Peaker, M. (1998) ‘Autocrine regulation of milk secretion’, Biochemical Society Symposium, 63, pp. 81–90.

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

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

Swallowing is an essential part of milk transfer during infant feeding. Sucking draws milk into the mouth, but getting milk into the mouth is only the beginning of the process. The milk needs to be contained and organised as a bolus, moved towards the back of the mouth, and then transferred onwards through the pharynx and oesophagus towards the stomach. The tongue plays an important role in moving the milk posteriorly. As the milk bolus reaches the oropharyngeal area, sensory input contributes to the initiation of the pharyngeal swallow. The pharyngeal phase then propels the milk through the pharynx and into the oesophagus, followed by oesophageal transport towards the stomach (Lau, 2015; Jadcherla et al., 2017). Swallowing is often described using a four-phase model: oral preparatory, oral transit or propulsive, pharyngeal and oesophageal phases. However, infant feeding literature also commonly describes three broader phases — oral, pharyngeal and oesophageal — with the oral phase incorporating the preparation and propulsion of the milk bolus. The terminology therefore varies between sources, but the underlying sequence remains the same: milk enters the mouth, is organised and moved posteriorly, the swallow is initiated, and the milk is transported onwards (Lau, 2015; Jadcherla et al., 2017). During a feed, swallowing is coordinated with sucking and breathing. This coordination develops as an infant matures and can vary according to the baby's developmental stage, the feeding method and the rate at which milk is available (Mizuno, Ueda and Takeuchi, 2002; Mizuno and Ueda, 2003). Although the swallow itself occurs internally, some of the associated movement can be observed externally. Learning what to look for can therefore help families recognise when active swallowing is taking place during a breast or bottle feed. Recognising a swallow during a feed One of the most useful places to observe swallowing is underneath your baby's chin, towards the upper front of the neck. During a swallow, this area draws inwards and deepens. Breathing movements can also be seen in the neck, but these are further down the neck, so they can be distinguished from the movement associated with swallowing. The external movement does not mean that the swallow itself can be seen directly. The swallow takes place within the mouth and throat, while the movement underneath the chin provides an observable indication that the swallowing mechanism is occurring. Ultrasound studies have been used to examine what is happening internally during breastfeeding. Geddes et al. (2010), for example, used ultrasound imaging to observe milk movement during infant swallowing and demonstrated the relationship between swallowing, milk movement and respiratory pauses. This provides a useful reminder that the movement seen from outside the baby's body is only one visible part of a much more complex physiological process. Swallowing may also be audible, although an audible sound is not essential for a swallow to be occurring. A clear swallowing sound can accompany milk being transferred, but sounds heard during a feed need to be interpreted carefully. Noisy sucking, clicking or repeated gulping can also occur when air is being drawn into the mouth, particularly where the seal between the baby's mouth and the breast or teat is not being maintained. In that situation, the sound should not automatically be interpreted as evidence of effective milk transfer. Where audible air intake is accompanied by clicking, milk leakage, loss of suction or other signs of difficulty maintaining attachment, the wider feeding pattern is more informative than the sound alone. For a visual demonstration of what swallowing can look like at the breast, Lucy Webber IBCLC's video *Recognising when a baby is swallowing effectively at the breast* shows the external signs to look for (Webber, 2026). What can swallowing look like during a feed? There is considerable variation in how sucking, swallowing and breathing are coordinated between babies and between different stages of the same feed. There is therefore no single pattern that every baby should demonstrate. During active feeding, sucking draws milk into the mouth and swallowing moves that milk onwards. A baby does not necessarily need to swallow after every suck. The number of sucking movements between swallows can change according to milk flow, the baby's developmental maturity and what is happening during the feed. At the breast, some babies may begin with a period of quicker sucking associated with stimulating milk ejection before settling into a pattern in which sucking and swallowing become more closely associated with active milk transfer. NHS guidance describes feeds as often beginning with a few rapid sucks before progressing to longer, rhythmic sucks and swallows, with occasional pauses (NHS, 2026). Breastfeeding also serves purposes beyond nutritional intake. Babies may breastfeed for comfort, reassurance, closeness and regulation as well as to obtain milk. This means that a baby may move between periods of active milk transfer and periods of lighter or more comfort-focused sucking during the same breastfeeding episode. The presence of fewer visible swallows during such a period does not necessarily indicate a problem with milk transfer, because the purpose of the sucking may have changed. The overall pattern of the feed, the baby's coordination and the presence of sustained active milk transfer provide more useful information than whether an individual feed follows a particular sequence. Rhythm, milk flow and swallowing Observing swallowing over a meaningful period of active feeding is generally more informative than focusing on one isolated swallow. The rhythm of swallowing can change as milk flow changes, and this can happen naturally during both breast and bottle feeding. When milk is readily available and flowing more quickly, swallows may occur closer together because the baby has milk available to move onwards. As the flow slows, there may be more sucking movements between individual swallows. The resulting pattern may therefore become less frequent without this necessarily indicating a problem. At the breast, milk flow is dynamic rather than constant. It can change during milk ejection and as the feed progresses, so the spacing between visible swallows may change accordingly. A baby may therefore have periods in which swallowing is frequent and obvious, followed by periods in which more sucking occurs between swallows. Bottle feeding also involves changes in milk flow. Teat flow, bottle angle and the way the feed is offered can all influence how quickly milk reaches the baby's mouth. This is one reason that the baby's swallowing pattern should be considered alongside the way the bottle is being offered rather than interpreted in isolation. Counting visible swallows can sometimes be a useful observational aid. It can help a family or practitioner notice whether swallowing is occurring regularly during active feeding and whether the rhythm changes as milk flow changes. However, there is no prescribed number of visible swallows that a baby needs to achieve during a feed, and counting cannot determine the exact volume of milk transferred. What can swallowing tell you about milk transfer? Seeing repeated swallowing during a period of active feeding provides evidence that milk is being transferred beyond the mouth. It is therefore one useful part of observing milk transfer, but it cannot be used to calculate exactly how much milk a baby has taken. The amount of milk transferred depends on more than the number of visible swallows. The volume of milk contained in each bolus can vary, as can milk flow, sucking patterns and the baby's ability to maintain feeding over time. Two babies may therefore show different swallowing patterns while both are transferring milk effectively. Swallowing is best considered alongside the wider picture of feeding. This can include the baby's alertness and stamina, their ability to remain coordinated during the feed, whether they appear settled and satisfied afterwards, urine output, growth and other indicators of adequate milk intake. For further information about observing milk transfer during feeds, see Signs of Poor Milk Transfer in Your Baby at Feeds. Breastfeeding and swallowing At the breast, the pattern of sucking and swallowing can change considerably during a single breastfeeding episode. A period of rapid sucking may occur as the baby stimulates milk ejection, followed by a more sustained pattern of active sucking and swallowing once milk is flowing more readily. Ultrasound research has demonstrated the relationship between tongue movement, intra-oral vacuum and milk transfer during breastfeeding (Geddes, Kent, Mitoulas and Hartmann, 2008). Further ultrasound work has allowed researchers to observe the movement of milk during swallowing itself, providing information about the internal sequence that cannot be determined from external observation alone (Geddes et al., 2010). As milk flow changes, the visible rhythm of swallowing may change too. A baby may swallow frequently when milk is flowing readily and then have longer intervals between swallows when the flow becomes slower. It is also important to consider what the baby is using the breast for at that point in the feed. Breastfeeding is not exclusively about nutritional intake. A baby may continue to suckle for comfort or reassurance after active milk transfer has reduced, and the pattern of sucking and swallowing will consequently change. Periods of lighter sucking with fewer visible swallows can therefore occur within a breastfeeding episode without necessarily representing ineffective feeding. The observation is therefore not simply whether a swallow can be seen at one particular moment, but whether swallowing is occurring during periods of active milk transfer and how the baby's overall feeding pattern develops throughout the feed. Bottle feeding and swallowing Bottle feeding also requires coordination between sucking, swallowing and breathing. A 1:1:1 suck–swallow–breathe pattern can occur for some babies and at some stages of a feed, but it is not a universal requirement for effective bottle feeding. Other babies may take several sucks before swallowing, followed by a breath or pause. This is where paced bottle feeding can be particularly relevant. Paced feeding does not aim to make every feed follow a particular suck–swallow–breathe ratio. Instead, it can give the baby greater opportunity to regulate the rate of milk flow and take pauses according to their own feeding pattern. NHS guidance recommends keeping the bottle almost horizontal, allowing the baby to control the pace of the feed and providing opportunities for breaks when the baby shows cues that they need one (NHS, 2026). The baby's pauses can therefore form part of the feeding pattern rather than being something that needs to be eliminated. A baby may pause to breathe, rest or regulate the amount of milk entering the mouth before returning to active sucking and swallowing. Following these cues can help the rate of milk flow fit more closely with the baby's ability to coordinate feeding. The rate of milk flow can also influence the spacing between visible swallows. With a faster flow, milk may reach the mouth more readily and swallows may occur closer together. With a slower flow, more sucking may occur between swallows. Bottle position and feeding technique can influence this flow, which is why paced and responsive bottle feeding consider both the baby's cues and the way the bottle is presented (NHS, 2026). More information about paced bottle feeding and ways of supporting a responsive feeding rhythm can be found in How to Pace Bottle Feeds: A Calm, Practical Guide. When feeding may need further assessment Occasional changes in feeding rhythm are not, by themselves, evidence of a swallowing problem. However, persistent difficulties with coordination or signs that a baby is struggling to manage milk flow may warrant further assessment. Concerns can include repeated coughing, choking or spluttering during feeds, changes in colour, difficulty coordinating breathing with feeding, marked fatigue, frequent loss of milk from the mouth, or an inability to sustain effective feeding. A baby who repeatedly stops feeding because they appear unable to manage the flow of milk may also benefit from closer observation. These signs can have many possible causes, and swallowing should not be considered in isolation. A feeding assessment may consider the baby's oral movements, sucking pattern, breathing, milk flow, positioning, stamina and overall feeding behaviour alongside growth and other indicators of adequate intake. Recognising swallowing is therefore one part of observing infant feeding rather than a standalone test. Looking at the movement underneath the chin and upper front of the neck, and considering its frequency and rhythm across a substantial period of active feeding, can provide useful information about when swallowing is taking place. That observation becomes more meaningful when considered alongside the wider pattern of the feed and the baby's overall wellbeing. References Geddes, D.T., Chadwick, L.M., Kent, J.C., Garbin, C.P. and Hartmann, P.E. (2010) ‘Ultrasound imaging of infant swallowing during breast-feeding’, Dysphagia, 25(3), pp. 183–191. Available at: https://pubmed.ncbi.nlm.nih.gov/19626366/ Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. Available at: https://pubmed.ncbi.nlm.nih.gov/18262736/ Jadcherla, S.R. et al. (2017) ‘Advances with neonatal aerodigestive science in the pursuit of safe swallowing in infants: invited review’, Dysphagia, 32(1), pp. 15–26. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5303645/ Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4530609/ Mizuno, K., Ueda, A. and Takeuchi, T. (2002) ‘Effects of different fluids on the relationship between swallowing and breathing during nutritive sucking in neonates’, Biology of the Neonate, 81(1), pp. 45–50. Available at: https://pubmed.ncbi.nlm.nih.gov/11803176/ Mizuno, K. and Ueda, A. (2003) ‘The maturation and coordination of sucking, swallowing, and respiration in preterm infants’, The Journal of Pediatrics, 142(1), pp. 36–40. Available at: https://pubmed.ncbi.nlm.nih.gov/12520252/ NHS (2026) ‘Bottle feeding your baby’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/ NHS (2026) ‘Bottle feeding your baby: Feeding on demand’, NHS Best Start in Life. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/bottle-feeding-your-baby/feeding-on-demand/ Webber, L. (2026) ‘Recognising when a baby is swallowing effectively at the breast’, YouTube, 25 January. Available at: https://www.youtube.com/watch?v=AjCd3wqMmwM

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

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

Breastfeeding can last for a day, several months, a couple of years or longer. Whenever your breastfeeding journey comes to an end, it is a change in feeding rather than a measure of how well you have done. There are many different reasons why someone may decide to stop breastfeeding. Health, medication, returning to work, changes within the family, feeding difficulties or simply feeling that the time is right can all be part of that decision. Research exploring why mothers stop breastfeeding has found that the reasons can be complex and can change throughout the first year (Li et al., 2008). The decision to stop may be completely baby-led, completely mother-led, or somewhere in between. It may also be a gradual change rather than a single decision to stop altogether. The Academy of Breastfeeding Medicine recognises that weaning can happen in different ways and that families may combine breastfeeding with expressed milk, formula or other forms of feeding during the transition (ABM, 2026). The reasons for stopping are not the focus here. Instead, this article looks at what stopping breastfeeding can involve, what your baby may need as feeds change, and how you can look after yourself and your breasts during the transition. However you choose to stop, your own wellbeing matters too. Weaning is a hormonal journey as well as a feeding journey, and some mothers find that the end of breastfeeding brings unexpected emotions, even when the decision feels right. Looking after yourself with regular food, a balanced diet, rest where possible, enough fluid to respond to your thirst, and practical or emotional support can make a difference. Stopping breastfeeding also opens another journey rather than simply bringing one to an end. There is no set age to stop breastfeeding There is no particular age when breastfeeding has to stop. The NHS describes when breastfeeding ends as a decision for you and your baby, while the World Health Organization recommends exclusive breastfeeding for around the first six months, followed by complementary foods alongside continued breastfeeding to two years and beyond, for as long as mutually desired (NHS, 2026a; WHO, 2026). Natural weaning is usually a gradual process. A baby may become increasingly interested in food, other ways of drinking, exploring their surroundings and the wider world around them while still enjoying breastfeeds. It is uncommon for a baby to completely self-wean during early infancy. A change in feeding behaviour does not necessarily mean that a baby is ready to stop breastfeeding altogether, particularly during periods of illness, developmental change or changes in routine. There is therefore no need to stop simply because your baby has reached a particular age. Equally, there is no requirement to continue beyond the point that feels right for you and your baby. What does weaning actually mean? The word weaning can mean different things to different families. Sometimes weaning refers to introducing solid foods. Sometimes it means gradually reducing breastfeeding. It may mean moving from direct breastfeeding to expressed breast milk, introducing formula, combining breastfeeding with another form of feeding, or gradually stopping breast milk altogether. These changes do not have to happen all at once. You may continue breastfeeding some of the time while replacing other feeds. You may keep a morning or bedtime breastfeed for much longer than daytime feeds. You may reduce feeds during the day while continuing to breastfeed at night. There is no requirement for weaning to be an all-or-nothing process. It is also worth separating the introduction of complementary foods from stopping breast milk. From around six months, babies can begin to explore solid foods, but breast milk or first infant formula remains an important source of nutrition during the first year (NHS, 2026b). What does my baby need instead? What replaces a breastfeed depends largely on your baby's age and what you want feeding to look like after breastfeeding reduces. Under 12 months old For babies under 12 months, breast milk or first infant formula remains their main drink. If breastfeeding is stopping and expressed breast milk is not being used, first infant formula is the appropriate replacement milk (ABM, 2026; NHS, 2026c). From around six months, babies can begin drinking from a cup as they develop the skills to do so. An open cup or free-flow cup without a valve can help babies learn to sip, and offering a cup with meals can become part of everyday feeding (NHS, 2026c). If you are moving from breastfeeding to bottles, paced bottle feeding can help keep the feeding experience responsive to your baby's cues. If you are choosing another way of offering milk, there are also alternatives to bottles. You can read more in my blogs [Alternative Feeding Methods for Babies] and [How to Pace Bottle Feeds]. Cows' milk can be used in cooking or mixed into foods from around six months, but it should not be given as a main drink until your baby is 12 months old. This is an important distinction: when NHS guidance refers to cows' milk from around six months, it means as part of food rather than as the milk drink replacing breast milk or first infant formula (NHS, 2026b; NHS, 2026c). From 12 months old From 12 months, pasteurised whole cows' milk can be offered as a main drink. Breast milk can also continue if you and your child wish to do so. Toddler or growing-up milks are not needed routinely after 12 months. The NHS recommends full-fat dairy products for children under two because young children need the energy and nutrients they provide (NHS, 2026d). How can breastfeeding be stopped? There is no single method that suits every feeding dyad. For many families, gradually reducing breastfeeds is the most comfortable approach, but there are several ways to make a transition. Gradual reduction Gradually reducing milk removal gives your breasts time to adjust as your milk production decreases. You might choose to: replace one breastfeed each day with another form of feeding shorten particular breastfeeds gradually increase the time between breastfeeds reduce particular feeds while continuing others remove daytime feeds while keeping a morning or bedtime feed reduce the frequency or duration of feeds over a period of weeks or months. There is no fixed timetable. Some families make changes over several days, while others take several weeks or longer. The important thing is that you do not have to stop every feed at the same time. Gradual reduction can also help reduce the likelihood of uncomfortable breast fullness and may reduce the risk of inflammation or mastitis associated with sudden changes in milk removal (ABM, 2026; NHS, 2026e). If you are only reducing some breastfeeds, you may not need to stop milk production altogether. Partial weaning can be a long-term feeding arrangement in its own right. Expressing may be part of the transition Expressing can be another way of managing the transition, particularly if you want to continue giving your baby breast milk while reducing or stopping direct breastfeeding. It is important to remember that expressed milk volume is not a direct measurement of how much milk your body produces. Milk production and milk removal are related, but they are not the same thing. The amount collected by a breast pump is influenced by the pump and its settings, flange fit, timing, breast fullness, milk ejection and the individual's response to expressing. Research also shows that milk output can vary considerably between breasts and between expressing sessions (Wambach et al., 2007; Geddes et al., 2023). Milk yield, viscosity and composition can also change during and between expressing sessions. A particular pumping session therefore cannot tell you exactly how much milk you produce or what your baby would have removed at the breast. For example, the fat content of human milk changes as the breast is progressively emptied, and the average 24-hour fat content can differ from the fat concentration measured in an individual expressing session (Daly et al., 1993; Kent et al., 2013). You can read more about expressing in my blogs How to Express Breastmilk and Breast Pump Flange Fitting: Size, Shape, Comfort and Milk Removal. If your breasts become uncomfortably full while feeds are being reduced, you do not necessarily need to fully empty them. Expressing a small amount for comfort can take the edge off the pressure while allowing milk removal to continue reducing. The aim is comfort rather than completely draining the breast, because removing more milk provides a signal for the body to continue producing it. Ways of reducing milk production As milk removal reduces, milk production normally reduces too. There are also some approaches that can be used alongside gradual reduction to make the physical transition more comfortable or to support lactation suppression. Cold therapy Cold therapy is widely used as part of lactation suppression and is included in NICE guidance as a self-help measure when breastfeeding has stopped or needs to be stopped (NICE, 2021). Cold packs or cold compresses can reduce discomfort, swelling and breast congestion during the transition. They can be particularly useful when the breasts feel full or tender. Cold therapy does not need to be extreme. A cold pack wrapped in a cloth can be applied for a short period, allowing the skin to warm again afterwards. Some people also find chilled cabbage leaves comfortable. Cold therapy is about supporting the physiological transition and making breast fullness more manageable; it does not mean that you need to tolerate significant pain or leave your breasts painfully overfull. Herbal remedies A number of herbs have traditionally been used to reduce milk production, including sage, peppermint, parsley and jasmine. Chasteberry has also been described in relation to reducing milk supply. The evidence is very different between these remedies, and traditional use should not be confused with good evidence that a particular herb will reliably reduce milk production. Information about these herbs is not a recommendation to use them, and this article does not provide instructions for preparation, dosage or frequency. An herb used as a food ingredient is not necessarily equivalent to a concentrated tea, tincture, capsule, extract or other supplement. The strength and ingredients of herbal products can vary, and the effects of some preparations on health, milk production and breastfed babies are not well understood. Herbal medicines can have pharmacological effects and can interact with medicines or affect how medicines work. This is particularly important if you take medication for a health condition or are using hormonal medicines, including contraception. Your underlying health conditions and current medicines may also themselves affect milk production. For example, medicines used for thyroid conditions and diabetes can be relevant when considering changes in milk supply, while some hormonal contraceptives can also affect lactation. Do not stop, reduce or change a prescribed medicine in an attempt to alter your milk supply. If you are considering using an herb or herbal preparation while reducing or stopping breastfeeding, speak with a pharmacist, GP, appropriately qualified healthcare professional or other professional who can check the specific preparation against your medical history, current medicines and other supplements. This is particularly important because safety information may be limited and some products have not been adequately studied during breastfeeding. Sage is traditionally used for weaning and oversupply, but LactMed reports that no scientific studies evaluating its effect on milk supply could be located. Sage also contains compounds including thujone and camphor, which can be neurotoxic in high doses, and there are limited safety data for breastfeeding mothers and infants (LactMed, 2025a). Peppermint is also traditionally used to suppress milk production. Laboratory and animal research suggests that menthol can affect milk production, but no clinical trials demonstrating lactation suppression in humans have been identified. Large amounts of peppermint can also cause gastrointestinal symptoms, and some peppermint constituents pass into breast milk (LactMed, 2025b). Parsley has been included in traditional preparations intended to reduce milk flow, but LactMed reports that there are no scientifically valid clinical trials supporting this use (LactMed, 2024a). Jasmine has a history of traditional use for lactation suppression, and one study found that applying jasmine leaves to the breasts reduced postpartum lactation. However, the study was considered low quality and there are insufficient data about safety and effectiveness (LactMed, 2021). Chasteberry has also been used traditionally to reduce milk supply, but the evidence is uncertain. Importantly, LactMed advises avoiding chasteberry during lactation because of concerns about its safety and its potential effects on lactation (LactMed, 2024b). Medicines and other factors that can affect milk production Some medicines can affect milk production. One example is pseudoephedrine, a decongestant sometimes known by the brand name Sudafed. Research has found that a single dose can temporarily reduce milk production and that repeated use can interfere with lactation (LactMed, 2026). This does not make pseudoephedrine a routine weaning treatment. It is a medicine with its own contraindications, interactions and potential adverse effects, so it should not be used specifically to stop breastfeeding without appropriate individual medical advice. It is also worth remembering that medicines and health conditions can affect milk production in different ways. If your milk production has changed unexpectedly, or you are taking medication for a long-term health condition, discuss this with your healthcare professional rather than assuming that the medication or condition should simply be changed. If breastfeeding needs to stop more quickly Sometimes gradual reduction is not possible or is not what someone needs. There may be a medical reason, an urgent change in circumstances, medication that makes breastfeeding temporarily or permanently unsuitable, pregnancy or infant loss, or a situation in which continuing to breastfeed is affecting a mother's physical or emotional wellbeing. If mental health or a sense of safety is part of the reason that breastfeeding needs to stop quickly, that matters too. You do not need to justify your decision before receiving support. Stopping abruptly Stopping suddenly means that milk removal decreases much more quickly, which can leave the breasts feeling very full, painful or swollen. If stopping abruptly is necessary, reducing breast stimulation and expressing only enough milk to relieve significant discomfort can help. Cold packs, a comfortable supportive bra and appropriate pain relief may also help with symptoms (NICE, 2021). If you develop a worsening painful area, increasing redness or swelling, fever, flu-like symptoms or feel significantly unwell, seek medical advice rather than assuming that you simply need to push through the discomfort (NHS, 2026e). Medication to suppress lactation Cabergoline is a prescription medicine that suppresses prolactin and can be used to inhibit or suppress physiological lactation in specific circumstances. If you think medication may be appropriate because breastfeeding needs to stop quickly, this is something to discuss with your GP, midwife, obstetric team or another appropriate healthcare professional. It may be considered after childbirth when breastfeeding is not going to be started, when breastfeeding is contraindicated for medical reasons, or following stillbirth or abortion. It may also be used in other specific medical circumstances following clinical assessment (eMC, 2025). Cabergoline is therefore not a self-help method or a routine shortcut for planned weaning. Whether it is appropriate depends on the individual circumstances, medical history and reason for lactation suppression. What about breast binding? Tightly binding or compressing the breasts is not recommended as a way of stopping breastfeeding. Breast binding is an old method of attempting to suppress milk production, but it is no longer recommended. Research has not demonstrated a useful benefit from binding, and it can increase breast discomfort, tenderness and leakage. It may also place unnecessary pressure on breast tissue. A comfortable, supportive bra can provide support while the breasts are changing, but tight compression is not needed to reduce milk production and can cause unnecessary pain and discomfort. There are now more comfortable and evidence-informed approaches to managing breast fullness during weaning, including gradual reduction of milk removal, expressing small amounts for comfort when necessary and cold therapy. Looking after yourself while weaning Stopping breastfeeding is a physical and hormonal change as well as an emotional one. As milk production changes, hormone levels change too. Some mothers notice very little emotional change, while others experience sadness, irritability, tearfulness or a sense of loss around the end of breastfeeding. This can happen even when stopping feels completely right. Regular meals, enough fluid according to thirst, rest where possible and support from people you trust can all be useful during the transition. It can also help to give yourself permission to notice the emotions without assuming that they mean you have made the wrong decision. If you experience persistent low mood, significant anxiety, intrusive thoughts or feel that you are struggling to cope, seek appropriate support. When your breastfeeding journey comes to an end Whether your breastfeeding journey lasted a day, several months, a year, several years or longer, it was part of your relationship with your baby. There does not need to be a particular way for the journey to end. It may happen gradually, one feed at a time. It may involve expressed milk, formula, cups, bottles, solid foods or a combination of different ways of feeding. It may be entirely your decision, entirely your baby's timing, or something you navigate together. Stopping breastfeeding does not erase everything that came before it. It is simply a change in feeding — and the beginning of another stage in your journey together. References Academy of Breastfeeding Medicine (2026) Questions mums ask about stopping breastfeeding. Patient information leaflet. Daly, S.E.J., Di Rosso, A., Owens, R.A. and Hartmann, P.E. (1993) ‘Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk’, Experimental Physiology, 78(4), pp. 543–551. https://pubmed.ncbi.nlm.nih.gov/8311942/ eMC (2025) Cabergoline 0.5mg Tablets: Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/101200/smpc Geddes, D.T., Gridneva, Z., Perrella, S.L., Mitoulas, L.R., Kent, J.C. and Hartmann, P.E. (2023) ‘Infant factors that impact the ecology of human milk secretion and composition’, Frontiers in Nutrition, 10. https://pmc.ncbi.nlm.nih.gov/articles/PMC10356564/ LactMed (2021) Jasmine. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501843/ LactMed (2024a) Parsley. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501880/ LactMed (2024b) Chasteberry. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501807/ LactMed (2025a) Sage. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501816/ LactMed (2025b) Peppermint. Drugs and Lactation Database. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501851/ LactMed (2026) Pseudoephedrine. Drugs and Lactation Database. National Library of Medicine. Li, R., Fein, S.B., Chen, J. and Grummer-Strawn, L.M. (2008) ‘Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year’, Pediatrics, 122(Supplement 2), pp. S69–S76. https://doi.org/10.1542/peds.2008-1315i National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. https://www.nice.org.uk/guidance/ng194 NHS (2026a) How to stop breastfeeding. NHS. NHS (2026b) Your baby's first solid foods. NHS. NHS (2026c) Drinks and cups for babies and young children. NHS. NHS (2026d) What to feed young children. NHS. NHS (2026e) Mastitis. NHS. Wambach, K.A., Spencer, B., March, K., Lairson, P. and Arnold, L. (2007) ‘Comparison of milk output between breasts in pump-dependent mothers’, Journal of Human Lactation, 23(4), pp. 399–405. https://doi.org/10.1177/0890334407307575 World Health Organization (WHO) (2026) Breastfeeding. WHO.

“Has my baby’s tongue-tie reformed?” is an understandably worrying question, particularly when feeding remains difficult or the area under the tongue looks different during healing. Tongue-tie reformation is a term often used to describe concern that restriction has returned after a frenulotomy. It is not, however, a precise diagnosis. A careful response starts with the infant’s feeding, comfort and tongue function, rather than appearance alone. For families, this uncertainty can feel especially hard after making a considered decision about a procedure. For professionals, it is a reminder that anatomy provides information, while function provides context. Healing, feeding and infant development are dynamic, and a thoughtful review is more useful than assuming that every ongoing difficulty represents recurrent restriction. What does tongue-tie reformation mean? In everyday conversation, reformation may refer to several different things: normal healing tissue being visible, a frenulum that appears prominent again, scar tissue, or a concern that tongue movement is limited after a previous release. These are not interchangeable findings, and none can confirm a clinically significant problem without considering function and feeding. The published literature does not offer a consistent definition of reformation or reattachment after infant frenulotomy. Studies use differing terminology, outcome measures and follow-up periods. This makes it difficult to quote a reliable rate or to know whether reports from one setting apply to another. It also means that a visual finding, taken in isolation, should be interpreted cautiously. A frenulum is a normal anatomical structure. Following a frenulotomy, the area heals and its colour, texture and appearance may change over time. A pale or yellowish healing surface can be part of normal wound healing, but photographs or remote descriptions cannot reliably distinguish normal healing from a problem. Families should be offered clear aftercare information and an appropriate route to seek review when something does not feel right. Why feeding may still be difficult Frenulotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term feeding outcomes is less certain. A Cochrane review found that the small trials available suggested short-term improvement in nipple pain, while demonstrating inconsistent effects on infant breastfeeding measures (O’Shea et al., 2017). Systematic reviews have similarly identified limitations in study size, follow-up and outcome reporting (Francis et al., 2015). This matters when considering tongue-tie reformation. Continuing pain, clicking, lengthy feeds, milk transfer concerns or bottle-feeding difficulties may warrant support, but they do not automatically establish that a restriction has returned. Feeding can be influenced by positioning and attachment, milk supply, breast and nipple anatomy, infant prematurity, jaundice, neurological or muscular differences, reflux-like symptoms, flow preferences, bottle-feeding dynamics and the cumulative effect of a stressful feeding journey. Sometimes the original restriction may not have been the main contributor to the difficulty. At other times, feeding has become associated with tension or distress, and the infant and parent need skilled, unhurried support as they regain confidence. These possibilities are not a reason to dismiss a family’s concerns. They are a reason to assess the whole picture. Function needs to be observed, not presumed A meaningful review brings together the feeding history, parental experience, infant growth and wellbeing, observation of a feed where appropriate, and assessment of oral function within the clinician’s scope of practice. For breastfed babies, this may include comfort, attachment, audible swallowing and signs of milk transfer. For bottle-fed babies, it may include seal, coordination, endurance, coughing or spluttering, and whether feeding is comfortable and sustainable for the family. No single sign proves that a tongue-tie is causing a problem. Equally, an infant can have a visible frenulum and feed effectively. The Academy of Breastfeeding Medicine advises that tongue-tie is a functional diagnosis and that the presence of a sublingual frenulum alone is not an indication for surgery (Academy of Breastfeeding Medicine, 2021). What does the evidence say about aftercare? Families may encounter confident claims that a particular aftercare routine can prevent reformation. Current evidence does not support certainty here. There is insufficient high-quality evidence that manual manipulation of a healing frenulotomy site prevents reattachment or improves feeding outcomes. The Academy of Breastfeeding Medicine states that evidence is lacking to support manual manipulation or stretching at the surgical site after a frenulotomy (Academy of Breastfeeding Medicine, 2021). The American Academy of Pediatrics similarly advises against recommending post-frenotomy stretching exercises in which parents reopen the wound, noting the absence of evidence for benefit and the potential for harm or distress (Thomas et al., 2024). This does not mean families should be left without follow-up. It means follow-up should focus on healing, feeding, parental concerns and individual clinical need rather than a universal wound-focused routine. Gentle oral activities may sometimes be discussed by appropriately trained professionals as part of wider feeding support, but they are not a substitute for assessment and should not be presented as a guaranteed way to prevent reformation. The distinction matters: supporting feeding function is different from asking a parent to manage a healing wound. When should families seek a review? Contact the treating service, GP, midwife, health visitor or an appropriately qualified infant feeding professional if feeding pain is persisting or worsening, feeds are increasingly stressful, there are concerns about intake or growth, or the healing area causes concern. Urgent medical advice is needed if an infant is unwell, unusually sleepy, has a fever, refuses feeds, or there are signs of bleeding or infection. A follow-up appointment is also valuable when the question is simply, “Is this healing normally?” Reassurance has greatest value when it is based on seeing the infant and hearing the family’s experience, not on generalised advice. Parents do not need to prove that something is wrong before asking for support. For healthcare professionals, careful language can reduce anxiety. Rather than confirming “reformation” from appearance, describe the finding, ask what has changed in feeding, and consider plausible differential explanations. If concerns persist, collaborative review may involve the clinician who performed the frenulotomy, an infant feeding specialist and the infant’s wider healthcare team. Repeat procedures require careful reasoning A repeat frenulotomy should not be assumed to be the next step because feeding remains challenging or tissue is visible. The decision requires an individual assessment of potential benefit, uncertainty and burden, alongside conservative feeding support where appropriate. The evidence base does not support a one-size-fits-all pathway, and families deserve transparent discussion of what is known and what remains uncertain. Clinical consensus guidance emphasises the need for informed consent, appropriate assessment and attention to alternative causes of feeding difficulty (Messner et al., 2020). A family may decide that further assessment, targeted feeding support, watchful waiting or another clinical opinion best fits their circumstances. Each can be a valid, supported choice. A calmer way forward The language of tongue-tie reformation can make a complex healing and feeding experience sound simple: the tie is either back or it is not. In reality, the most useful question is often, “How is this baby feeding, growing and feeling now, and what support does this family need?” A skilled, compassionate review can make space for both the clinical findings and the lived experience behind them. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. Messner, A.H., Walsh, J., Rosenfeld, R.M., Schwartz, S.R., Ishman, S.L., Baldassari, C., Brietzke, S.E., Darrow, D.H., Goldstein, N.A., Levi, J., Meyer, A.K., Parikh, S.R., Simons, J.P., Wang, M.B., Walsh, S.A. and Wax, M.K. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. Thomas, J., Bunik, M., Holmes, A., et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 153(2), e2023064054.

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

There is no single breastfeeding position that every caregiver and baby needs to use, and you may find you change the way you hold your baby throughout your feeding journey for all sorts of reasons. A position that felt comfortable when your baby was newborn may not feel quite so practical a few months later, while a position you initially struggled with may become your favourite once your baby is bigger and more confident at the breast. You may have been shown a particular position in hospital or by a midwife or breastfeeding supporter, only to discover that it does not feel quite the same when you are sitting on your own sofa at 3am. That does not mean you are doing it wrong. Breastfeeding positions are not fixed techniques that have to be reproduced exactly. They are different ways of arranging your bodies so that your baby can come comfortably to the breast and you can sustain the feed. The important thing is not whether your baby looks as though they are in a particular "correct" position. What matters is whether you are comfortable, your baby can attach well and feeding is working for you both. Start with positioning before thinking about the latch Positioning and attachment are closely connected, but they are not quite the same thing. Positioning is about how you arrange yourself and your baby in relation to the breast, while attachment describes how your baby takes the breast into their mouth. A baby can appear to be in a good position but still attach shallowly or uncomfortably. Equally, changing the way you position your baby can sometimes make it much easier for them to achieve a deeper and more comfortable attachment. Before thinking about exactly where your baby's mouth should go, it is worth considering your own position too. You need to be comfortable enough to remain there for the duration of the feed. Supporting your back, arms or feet can make a considerable difference, particularly during long or frequent feeds. The aim is not to hold your baby in a particular pose but to create an arrangement in which your baby can come close to the breast without you having to lean forwards, twist or hold their weight entirely with your arms. For more about the principles of attachment and getting a deeper latch, see How to improve infant latch: practical breastfeeding support. Your baby's whole body matters It is easy to focus on the baby's mouth because that is where the latch happens, but the rest of the body matters too. Your baby's chest and tummy will generally be facing towards you, with their body close enough to the breast that they do not have to stretch or twist to reach it. Their head, neck and body should be reasonably well aligned rather than their head being turned towards the breast while their body faces somewhere else. A useful principle is to think about your baby's ear, shoulder and hip being in a straight line. This does not mean that your baby has to look rigid or perfectly symmetrical. Babies move, and different positions will naturally alter the angle of their body. The important point is that they are not twisted through the neck or body while trying to feed. You may also come across the memory aid CHINS: Close Head free In line Nose to nipple Sustainable CHINS is a useful way of remembering the underlying principles, rather than a requirement for your baby to look exactly the same at every feed. Research into CHINS has also explored how families experience using it as a breastfeeding memory aid, with participants describing it as useful particularly during the early stages of breastfeeding (Shotton and Collins, 2024). How your baby comes onto the breast The way your baby approaches the breast is important. Rather than bringing your baby's face directly towards the nipple as though the nipple were a target, your baby's head can be allowed to tip back as their mouth opens. Think about what happens when someone takes a large drink from a glass. They do not usually bring the glass directly towards the centre of their mouth while keeping their head completely still. As they take a larger drink, the head tilts back, the mouth opens and the drink enters the mouth from above. The same principle can help explain what happens when a baby comes onto the breast. Your baby's nose is level with the nipple, but their head is angled upwards, as though they are looking or pointing upwards towards your forehead. This creates the angle needed for the mouth to open widely while the chin comes towards the breast. As your baby's mouth opens, the lower jaw moves while the upper part of the skull remains relatively still. The breast itself is also not weightless. As the breast rests against the baby's chin, its weight can help the chin move downwards and encourage the lower jaw to take a greater mouthful of breast tissue. This means that the lower part of the attachment can contain more breast tissue, rather than the baby simply taking the nipple into the centre of the mouth. The breast is effectively coming up and over into the open mouth, with more tissue being taken into the mouth on the underside of the latch. In simple terms, think of it as nose to nipple, head angled upwards, mouth opens, chin leads and the breast goes up and over into the mouth. This is different from trying to line the nipple up with the centre of your baby's mouth like a bulls-eye and bringing the baby's face directly forwards onto it. The aim is for your baby to take a larger mouthful of breast tissue rather than attaching primarily to the nipple. Allowing the head to tip back also means you should avoid pushing the back of your baby's head forwards towards the breast. Your baby's head needs to be free enough to move as they open their mouth and attach. An asymmetrical latch A comfortable and effective attachment does not necessarily mean that the nipple sits in the exact centre of your baby's mouth. With an asymmetrical attachment, the nipple enters the mouth at an angle and the baby takes more breast tissue into the lower part of the mouth. This fits with the wider principle of allowing the chin to lead and the baby to take a larger mouthful of breast rather than simply attaching to the nipple itself. You may also notice that there is more of the darker nipple and areola skin visible above your baby's upper lip than below their lower lip. NHS guidance describes this as one of the signs that can be seen with effective attachment (NHS, 2026). It is important not to turn this into another "perfect latch" test, though. Areolas vary considerably in size, shape, colour and symmetry. Someone with a very large areola will naturally have a different visual appearance from someone with a small one, and the amount of visible areola may also be affected by individual breast anatomy. The marker is therefore most useful when considered alongside how the feeding feels, how your baby is feeding and what the attachment actually looks and feels like. The 'Flipple' technique The 'flipple' technique is a way of changing the starting angle of the nipple so that it is directed upwards towards the roof of the baby's mouth rather than forwards into the centre of the mouth. The term 'flipple' is used in breastfeeding support to describe this particular approach, but the named technique itself has limited specific research. The underlying principles are more established: starting with the baby's nose level with the nipple, allowing the head to tip back, waiting for a wide gape, bringing the chin to the breast first and allowing the nipple to enter the mouth towards the roof rather than aiming it straight forwards (NHS, 2026). To use the technique, start with your baby's nose level with your nipple and their head angled upwards towards your forehead. Support your breast so that the nipple is angled upwards. As your baby opens their mouth wide and brings their chin towards the breast, release the finger or thumb that was supporting the upper surface of the breast while continuing to support underneath. This allows the breast and nipple to move further into your baby's mouth. As the baby's mouth closes around the breast, their suction or vacuum can help draw the nipple further back towards the soft palate. The "flip" is therefore not about putting the nipple into your baby's mouth like a target. It changes the starting angle and allows your baby's gape, chin-first approach and suction to bring the breast further into the mouth. Breastfeeding should be comfortable A position can look technically good and still not be comfortable for you. There is no benefit in maintaining a position simply because someone has told you that it is the "right" one if your shoulders are aching, your back is strained or your baby's attachment is painful. This is one reason why the final part of CHINS is sustainable. A breastfeeding position needs to be something that you can actually maintain, particularly when feeds are frequent or long. Some initial tenderness can occur when breastfeeding is being established, but persistent or significant pain deserves attention rather than simply being accepted as part of breastfeeding. Persistent nipple or breast pain can have a number of possible causes, and the Academy of Breastfeeding Medicine recommends assessing the feeding dyad when pain persists rather than assuming that one explanation applies to everyone (Berens et al., 2016). For more about painful attachment, see Painful breastfeeding latch: support that helps. What if you have larger breasts? Breast size can influence which positions feel comfortable and how much support you need. This is not because there is a particular position that people with larger breasts are supposed to use, but because the breast itself may need more support while your baby comes to the breast. Some caregivers find a sandwich hold helpful, where the breast is gently compressed to make it easier for the baby to take a larger mouthful. A scissor hold, using the fingers to support the breast, is another option that some people find useful. Neither hold is compulsory. If your baby is attaching comfortably without you holding the breast, there is no reason to add another hand or another technique simply because you have been told you should. The shape and size of the breast can also mean that you need to position your baby slightly differently on one side compared with the other. Breasts are not necessarily identical, and there is nothing unusual about finding that one side works better with a slightly different arrangement. What about milk supply? Positioning is only one part of breastfeeding and should not be treated as a complete explanation for milk supply. Effective milk removal can influence milk production, so a comfortable attachment that allows your baby to transfer milk effectively can be relevant to supply. However, milk production and milk transfer are influenced by many factors, and concerns about supply need to be considered in the wider feeding picture rather than assuming that changing position will solve the problem. UNICEF UK Baby Friendly guidance includes positioning, attachment, milk production and milk transfer as related but distinct parts of assessing breastfeeding (UNICEF UK Baby Friendly Initiative, 2013). Different breastfeeding positions There are many named breastfeeding positions, but you do not need to learn all of them. They are simply different ways of arranging your bodies, and some will suit you better at particular times than others. The positions described below are examples rather than a list of positions that you need to learn. In fact, you can make up your own position if it is comfortable and effective for your feeding dyad. The names given to breastfeeding positions are useful for describing familiar arrangements, but babies and breasts do not always fit neatly into named categories. As long as your baby is well supported, their ear, shoulder and hip remain appropriately aligned, their head and neck are free to move, and they can come onto the breast comfortably and feed effectively, there is plenty of scope to experiment. In essence, if a baby wanted to feed upside down and both of you could safely and comfortably maintain the position, there is no breastfeeding rule that says the position has to have a particular name. The important principles are more useful than the label. Cradle hold The cradle hold is one of the positions many people recognise immediately. Your baby's body lies across your lap, with their head supported by the arm on the same side as the breast they are feeding from. It can be comfortable once you and your baby are confident with breastfeeding, particularly when your baby has good head and body control. However, it is not necessarily the easiest position for a newborn who is still learning to attach because it can be harder to control the baby's approach to the breast. Supporting your own arms and back can make a big difference. You should not need to lean forwards to keep your baby's mouth at the breast. Cross-cradle hold In the cross-cradle position, your baby lies across your body as in the cradle hold, but you use the opposite arm to support and guide your baby's body. This gives you more control over your baby's position and can be particularly useful while you are learning what helps your baby attach comfortably. It can also make it easier to see what your baby's mouth is doing as they come onto the breast. Once your baby is well attached, you may find that you can gradually relax your hold rather than continuing to actively control the feed. Rugby or football hold In the rugby or football position, your baby is tucked alongside your body rather than lying across the front of your tummy. Their legs point behind you and their head is positioned near the breast. Some people find this particularly useful after a caesarean birth because the baby's body does not need to rest across the abdomen. It can also be useful if you have larger breasts, if you want a different angle on the breast or when feeding twins. The NHS includes the rugby hold among its commonly used breastfeeding positions (NHS, 2026). Laid-back or reclined breastfeeding Laid-back breastfeeding is different from simply sitting slightly backwards while your baby lies beside you. In a true laid-back position, you are comfortably reclined and your baby is really lying against you, with their body supported on your body rather than simply being placed on their side next to you. Your baby's tummy can rest against your tummy or chest, with their body supported by yours. This can allow your baby to make use of their own movements and can be particularly useful when you want to give them more freedom to approach the breast. Research into laid-back breastfeeding has found associations with reduced nipple pain and trauma and improved positioning and attachment compared with some traditional positions, although the evidence has limitations and further research is needed (Wang et al., 2021). If you are very tired or there is any possibility that you may fall asleep, however, breastfeeding and sleeping are separate considerations. Sofas and armchairs are particularly unsafe places to fall asleep with a baby. The Lullaby Trust provides specific safer-sleep guidance for situations where feeding occurs in bed and for avoiding accidental sleep on sofas or chairs (The Lullaby Trust, 2026). Side-lying Side-lying can be particularly useful for night-time feeds or when sitting upright is uncomfortable. You and your baby lie facing one another, with your baby close enough to reach the breast without needing to twist their neck. The ear, shoulder and hip alignment remains useful here too. Your baby should not need to turn their head sharply towards the breast while their body faces the other direction. Side-lying can be comfortable for feeding, but it is important to distinguish feeding from sleep. If there is any chance you may fall asleep, consider the safer-sleep guidance for bed sharing and make sure you understand when bed sharing is not recommended. Never intentionally fall asleep with a baby on a sofa or armchair (The Lullaby Trust, 2026). Koala / Saddle position In a koala or saddle hold position, your baby is sitting more upright against your body rather than lying horizontally across your lap. This can work particularly well as babies become more capable of sitting with support and may suit babies who dislike being held horizontally for every feed. It can also be useful when a baby wants to remain more upright between or during feeds. There is no need to wait for a particular age before experimenting with a more upright position, provided your baby is properly supported and can feed comfortably. The seatbelt position The seatbelt position is a variation in which the baby sits more upright across your body, with their body and legs extending towards the opposite side, rather like a seatbelt crossing your torso. It can provide a useful alternative for an older baby who is becoming more mobile and no longer wants to remain in a traditional cradle position. As babies become stronger and more curious, you may find that the named positions become less useful than simply finding a stable arrangement that allows them to reach the breast comfortably. Dancer hold The dancer hold is a breastfeeding technique that provides additional support beneath a baby’s jaw while they feed. The baby is positioned facing the breast, with their body supported under the caregiver’s arm in a semi-reclined or football/rugby-style position, although the technique can be adapted to other breastfeeding positions. The caregiver supports the breast with one hand while using the thumb and fingers of the same hand to form a gentle U-shape beneath the baby’s cheeks and jaw. This can be particularly helpful for babies with low muscle tone, a less stable jaw, or difficulty maintaining a deep latch, as the additional support can help them maintain their position and sustain their latch during the feed. Older babies Breastfeeding positions often become much less formal as babies grow. A baby who once needed to be carefully supported across your lap may eventually climb onto you, kneel beside you, sit across your thigh or feed while you are both lying down. Older babies may also move around considerably during a feed, particularly if they are distracted or interested in what is happening around them. This does not necessarily mean that the attachment is poor. Development changes the way babies use their bodies, and the position that worked for a newborn may simply no longer be necessary. Twins and higher-order multiples With twins or higher-order multiples, feeding at the same time can be practical for some families, but it is not essential. Many babies in a multiple birth do not want to feed at the same time, particularly as they grow and develop their own feeding patterns. Feeding each baby separately is perfectly possible, and families can use a mixture of simultaneous and individual feeds depending on what works for them. The rugby or football position is often used when feeding twins simultaneously because it allows one baby to be positioned on each side of the body, but other combinations are possible too. The NHS specifically notes that trying different breastfeeding positions can help families find what suits them best when feeding twins or multiples (NHS, 2026). Changing position during a feed There is no reason to remain in one position for an entire feed if another position becomes more comfortable or seems to work better as the feed progresses. Your baby may change their own position as they become more relaxed, as milk flow changes or as the breast becomes softer, and you may find that your own body needs a different level of support after sitting in the same position for a while. Some feeding dyads naturally move between positions during a feed, while others find one position that remains comfortable from beginning to end. You may even find that one breast feels easier in one position and the other breast in another. As babies grow, their preferences can change too, so the position that worked when your baby was two weeks old may not be the position they choose at six months. Breastfeeding does not need to look the same every time, and there is nothing wrong with changing position simply because you and your baby prefer something different. If, however, you find yourself repeatedly changing positions because your baby cannot maintain the latch, feeding remains painful, your baby is struggling to transfer milk or feeds are becoming increasingly difficult, that is different from simply experimenting with positions. At that point, rather than continuing to try one position after another, it would be appropriate to have the feeding observed and evaluated by someone suitably qualified to assess breastfeeding and infant feeding. When changing position does not solve the problem Positioning can make a substantial difference, but it cannot explain or resolve every breastfeeding difficulty. If your baby repeatedly slips from the breast, you are experiencing persistent pain or nipple damage, feeds are exhausting, or there are concerns about milk transfer, milk production or your baby's growth, the feeding picture needs to be considered more broadly. A skilled feeding assessment should look at what is actually happening during the feed rather than simply matching a symptom to a particular position or anatomical finding. This may include your baby's attachment and milk transfer, your comfort, breast or nipple factors, milk production and flow, your baby's health and development, oral function and the interaction between all of these factors. This is where having a feed observed by someone appropriately qualified can be much more useful than being given another list of positions to try. The aim is to understand why feeding is difficult for this particular dyad and whether a change in position is actually likely to help. Persistent pain, repeated loss of attachment or concerns about feeding effectiveness therefore deserve a proper breastfeeding evaluation rather than an expectation that you should simply keep experimenting until you find the "right" position. The position that works is the one that works for you There is no prize for making breastfeeding look like the picture in a leaflet. The best position for you may change from feed to feed, breast to breast, day to day and as your baby grows. You may use a traditional cradle hold one day, feed lying down the next, discover that your baby prefers to feed upright for a while, or end up inventing something that does not have a name at all. The useful principles are simple: you and your baby need to be comfortable, your baby needs to be close and well supported, their body should be appropriately aligned, their head should be free to move and they should be able to open their mouth and come onto the breast comfortably. Breastfeeding positions are there to give you options, not rules. The position that works is the one that allows you and your baby to feed comfortably, effectively and sustainably. References Berens, P., Eglash, A., Malloy, M. and Steube, A.M. (2016) ‘ABM Clinical Protocol #26: Persistent pain with breastfeeding’, Breastfeeding Medicine, 11(2), pp. 46–53. doi:10.1089/bfm.2016.29002.pjb. NHS (2026) ‘Breastfeeding: positioning and attachment’. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/positioning-and-attachment/ NHS (2026) ‘Breastfeeding positions’. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/breastfeeding/how-to-breastfeed/breastfeeding-positions/ NHS (2026) ‘Feeding twins and multiples’. Available at: https://www.nhs.uk/baby/newborn-twins-and-multiples/feeding-twins-and-multiples/ Shotton, L. and Collins, T. (2024) ‘Breastfeeding mothers’ awareness and experience of using the breastfeeding memory aide CHINS: an exploratory descriptive qualitative study’, Reproductive, Female and Child Health, 3, e108. doi:10.1002/rfc2.108. The Lullaby Trust (2026) ‘Co-sleeping’. Available at: https://www.lullabytrust.org.uk/baby-safety/safer-sleep-information/co-sleeping/ UNICEF UK Baby Friendly Initiative (2013) ‘The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards’. London: UNICEF UK. UNICEF UK Baby Friendly Initiative (2020) ‘Supporting effective breastfeeding: CHIN principles’. London: UNICEF UK Baby Friendly Initiative. Wang, Z., Liu, Q., Min, L. and Mao, X. (2021) ‘The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis’, BMC Pregnancy and Childbirth, 21, 248. doi:10.1186/s12884-021-03714-8.

Feeding difficulties can look very different from one baby to another. A baby may have very short and frequent feeds, feed for a long time, repeatedly slip off the breast, become unsettled during feeds, or leave a caregiver experiencing ongoing pain. Bottle-feeding families may notice tiring or prolonged feeds, milk leaking, clicking, coughing, difficulty maintaining a comfortable seal or a baby who seems to struggle to coordinate feeding. These experiences can occur with breastfeeding, bottle feeding or combination feeding, and the same underlying factor does not necessarily explain every feeding difficulty. When feeding isn't going well, it can be tempting to look for one explanation. If a frenulum is noticed under the baby's tongue, tongue-tie may quickly become part of that conversation. Sometimes restricted tongue function is relevant to feeding, while at other times another factor may be contributing, or several things may be happening together. Looking beyond tongue-tie does not mean dismissing it. It means making sure that the whole feeding picture is considered. A feeding difficulty is not a diagnosis A feeding difficulty describes what is happening; it does not, by itself, tell us why it is happening. A baby who feeds for a long time may be experiencing difficulty maintaining an effective seal, but long feeds can also occur for other reasons. A baby who feeds very frequently may have difficulty transferring milk, but frequent feeding can also be completely appropriate at certain stages of infancy. Clicking can occur with changes in positioning or attachment, milk flow, oral coordination or other factors, and not every baby who clicks has a tongue-tie. The same applies to bottle feeding. Dribbling, coughing, milk loss, tiring, prolonged feeds or difficulty maintaining a seal may have several possible explanations. This is why a feeding assessment needs to look beyond a single symptom or a single anatomical finding. The current UK Infant Feeding Survey found that feeding difficulties are varied, with mothers reporting problems including reflux, colic or wind, breast or nipple discomfort, difficulty with latching, milk supply concerns, positioning difficulties and bottle-feeding difficulties. There are many possible contributors There are far more possible contributors to feeding difficulties than can reasonably be listed in one article, so the examples below are intended to illustrate the breadth of the feeding picture rather than provide an exhaustive list. Some factors may be temporary. Others may have been present from the beginning. Some may affect feeding directly, while others may influence how a baby approaches feeding or how easily they can coordinate the different movements involved. And sometimes more than one factor is present. Positioning and attachment For breastfeeding, positioning and attachment can make a substantial difference to how comfortably and effectively a baby feeds. A baby may appear to be attached while still having a shallow or unstable attachment, and this can contribute to nipple pain, slipping on and off the breast, clicking or concerns about milk transfer. Breastfeeding is also different from simply feeding from a nipple. The aim is not for a baby to draw only the nipple into the mouth in the way a bottle teat is drawn into the mouth. Effective breastfeeding involves a deeper attachment to the breast tissue, with the nipple drawn into the baby's mouth as part of that attachment. This distinction matters because nipple shape alone does not determine whether breastfeeding will be successful. Babies can breastfeed effectively with inverted or less prominent nipples when they are able to attach well to the breast. If positioning or attachment is difficult, this does not mean that tongue-tie is necessarily responsible. Equally, improving positioning and attachment does not rule out the possibility that restricted tongue function may also be contributing. A skilled feeding assessment can help separate these possibilities rather than assuming that one explains everything. Milk flow Milk flow can influence how a baby feeds. A very fast milk flow may leave a baby struggling to coordinate sucking, swallowing and breathing, while a slower flow may require a different feeding pattern. Changes in milk supply can also alter the way a baby behaves at the breast. For breastfeeding families, milk transfer and milk production are related but are not the same thing. A concern about supply therefore deserves consideration of the whole feeding pattern rather than automatically being attributed to tongue-tie. The NHS identifies positioning and attachment, feeding frequency, maternal and infant illness and several other factors as possible influences on milk supply, alongside restricted tongue movement in some babies. Maternal anatomy and feeding mechanics Maternal anatomy can form part of the feeding picture, but it is important not to suggest that a particular breast or nipple shape is inherently a problem. Nipple pain, nipple trauma or a nipple that appears misshapen after a feed may be useful clues that the feeding mechanics are worth exploring. They do not, however, mean that the shape of the nipple itself is causing the difficulty. Successful breastfeeding does not depend on having a particular nipple shape. What matters is how the baby attaches and feeds at the breast. This is another reason why looking at the feeding interaction itself can be more informative than focusing on one physical feature in isolation. Feeding coordination and developmental maturity Feeding requires considerable coordination. A baby has to organise sucking, swallowing and breathing while maintaining an effective seal and responding to the flow of milk. These skills develop and mature over time, and they can be influenced by gestational age, birth history, illness, neurological development, muscle tone and the baby's state at the time of feeding. A baby who was born prematurely, for example, may have very different feeding skills from a baby of the same chronological age who was born at term. Developmental maturity therefore needs to be considered alongside the feeding difficulty rather than assuming that every difficulty is caused by an anatomical restriction. Nasal congestion and breathing Babies need to coordinate breathing with feeding, and nasal congestion can make this more difficult. A blocked or congested nose may cause a baby to pause frequently, pull away from the breast or bottle, become unsettled, feed for shorter periods or tire more easily. Respiratory illness can temporarily change feeding even when oral function has not changed. If a baby is struggling to breathe comfortably during feeding, this needs appropriate assessment rather than being assumed to be a tongue-tie problem. Teething and changes in the mouth Teething can temporarily change feeding because a baby's gums and mouth may feel uncomfortable. During effective breastfeeding, the tongue should extend forwards over the lower gumline, helping to protect the breast from direct contact with the lower teeth. When a baby is well attached and feeding effectively, the caregiver should not normally feel the teeth during active feeding (Guóth-Gumberger, 2026). Teething can nevertheless make the baby's mouth sore, particularly when they are not actively feeding, and this may temporarily alter how readily they approach the breast or how they behave during feeds. The presence of teeth therefore does not automatically explain nipple pain or biting during breastfeeding. If feeding has become uncomfortable, the attachment and mechanics of the feed are worth reviewing. Illness and other medical factors Babies may feed differently when they are unwell. Even a relatively short-lived illness can affect appetite, alertness, breathing, stamina or willingness to feed. There can also be medical factors that are much more important to recognise. For example, a heart murmur should never simply be dismissed as an innocent explanation for feeding difficulties. Many babies with heart murmurs do have normal hearts, but a murmur can sometimes be associated with an underlying heart problem, which is why babies with murmurs are assessed and, where necessary, followed up. If a baby with a heart murmur is feeding poorly, becoming breathless or unusually sweaty during feeds, tiring markedly, failing to gain weight as expected, breathing unusually quickly, working harder to breathe, or developing pale, blue or mottled skin, these symptoms need medical assessment rather than being attributed to oral function. NHS guidance for families specifically advises urgent assessment when a baby with a murmur becomes unwell or develops these warning signs. These symptoms can have causes other than heart disease, but that is precisely why they need appropriate clinical assessment. Changes following routine immunisations Some babies are temporarily more sleepy, unsettled or uncomfortable following routine immunisations, and feeding may change for a short period as a result. Breastfeeding can also provide comfort during vaccination, with evidence that breastfeeding around vaccination can reduce crying and behavioural measures of pain in infants (Harrison et al., 2016). A temporary change in feeding following an immunisation does not necessarily indicate a new problem with oral function. Routine immunisations should not be delayed simply because a baby may temporarily feed differently. If a baby is significantly unwell following an immunisation, or a caregiver is concerned about their symptoms, appropriate medical advice should be sought. Learned compensations Sometimes a baby has experienced feeding difficulty for long enough that they develop learned compensations. A baby may find another way to maintain a seal, alter the way they use their jaw, change their tongue position, take frequent pauses or develop a particular feeding pattern that allows them to manage as well as they can. These compensations are not simply a matter of behaviour. They can become part of the baby's established feeding pattern. If the original contributing factor changes, the learned compensation may not disappear immediately. This is one reason why feeding may remain difficult even when an underlying problem has been addressed. It also means that continuing feeding difficulties do not automatically prove that a tongue-tie remains the problem, or that another procedure is required. The feeding pattern needs to be reassessed in its own right. Feeding frequency does not tell the whole story The number of feeds or the length of individual feeds can sometimes provide useful information, but neither measure can tell us on its own whether feeding is effective. Some babies naturally feed quickly. Others take longer. Some feed frequently because they are establishing milk production or going through a period of increased demand. Others may feed frequently because they are not transferring milk efficiently or are tiring during feeds. The same principle applies to bottle feeding. A baby who takes a long time to finish a bottle may be tired, poorly coordinated, affected by the flow rate, uncomfortable or experiencing another difficulty. A baby who takes very small amounts frequently may have a completely different reason for doing so. The pattern needs to be considered alongside the baby's behaviour, intake, growth, output, comfort and overall wellbeing. Sometimes several things are happening at once This is perhaps one of the most important reasons not to search for a single explanation. A baby may have nasal congestion at the same time as a fast milk flow. A caregiver may be experiencing nipple pain alongside positioning difficulties. A baby may be recovering from an illness while also becoming more unsettled because of disrupted sleep. A change in feeding may occur during teething. A baby may have developed learned compensations following an earlier period of feeding difficulty. These examples are deliberately varied because feeding difficulties do not always come neatly packaged as one identifiable problem. Sometimes there is a tongue-tie as well. Sometimes there is not. The purpose of a careful assessment is therefore not to find a particular diagnosis to fit the symptoms, but to understand what is actually happening during feeding and which factors may be relevant to that individual baby and feeding dyad. What if a tongue-tie is suspected? If a tongue-tie is suspected, the next step should be a skilled assessment rather than assuming that the appearance of the frenulum explains the feeding difficulty. The important question is whether the frenulum is restricting tongue function and motility in a way that is relevant to feeding. A useful assessment therefore needs to consider more than whether a frenulum can be seen. It should explore the baby's history, feeding pattern, oral structures, tongue movement and function, and, where possible, observe feeding itself. The NHS also recognises that not every baby with tongue-tie has feeding problems, and that feeding difficulties can occur in both breastfed and bottle-fed babies. Where infant feeding is affected, it is particularly valuable for the assessment to include someone with substantial specialist infant-feeding knowledge. An International Board Certified Lactation Consultant (IBCLC) is the internationally recognised gold-standard credential in professional lactation care, with specific education, clinical experience and examination requirements. This is particularly important because the current evidence does not support treating the presence of a frenulum in isolation. The 2024 UK Infant Feeding Survey found that, among mothers reporting a diagnosed tongue-tie, 23% reported no feeding problems, while others reported breastfeeding, bottle-feeding or both being affected. A tongue-tie assessment should therefore answer a more useful question than simply “Does my baby have a tongue-tie?” It should help explore whether restricted tongue function is actually contributing to the feeding difficulty. You can read more about this in What Does a Tongue-Tie Assessment Consider? and Tongue-Tie Restriction in Babies (UK). If a tongue-tie is identified, treatment is not the only question Finding a tongue-tie does not automatically mean that a frenulotomy is required. The next question is whether the restriction is clinically relevant to the feeding difficulties being experienced and what options are available. For some babies and families, skilled feeding support and review may be sufficient. For others, persistent functional difficulties may lead to a discussion about frenulotomy. The decision needs to take account of the assessment findings, the baby's feeding, the potential benefits and limitations of treatment, the risks of the procedure and the family's own circumstances and priorities. You can explore these decisions in more detail in Surgical Release or Conservative Management for My Baby's Tongue-Tie. If a frenulotomy is being considered, families may also want to understand the procedure itself, the different methods used, the evidence and the possible risks. Those questions are explored separately in What a Frenotomy Procedure Means for Your Baby and Frenulotomy Methods in Infants: What Matters?. Aftercare and feeding support also deserve their own consideration. A frenulotomy addresses a restrictive frenulum; it does not automatically resolve every contributor to feeding difficulty, particularly where a baby has already developed compensatory feeding patterns. Beyond the Tongue-Tie Release: Why Aftercare Matters explores why feeding support continues to matter after the procedure. When should feeding difficulties be reviewed? Persistent feeding difficulty deserves attention whether or not a tongue-tie is visible. It is particularly important to seek appropriate help if feeding is painful, exhausting, increasingly difficult, associated with concerns about intake or weight gain, or if a baby is regularly coughing, choking, becoming breathless, tiring excessively or appearing distressed during feeds. Medical assessment is important when feeding changes occur alongside signs of illness, breathing difficulty, poor weight gain, unusual lethargy, colour change or other symptoms that suggest the baby may be unwell. A tongue-tie assessment may be appropriate when restricted tongue movement is suspected, but it should not replace medical assessment where a baby's symptoms could have another cause. Looking at the whole feeding picture There is no single sign that can tell a family why feeding is difficult. A baby may have a tongue-tie and feed well. A baby may have significant feeding difficulties without a tongue-tie. Another baby may have restricted tongue function alongside several other factors that are affecting feeding at the same time. The most useful starting point is therefore the baby in front of you and the feeding that is actually happening. That means considering how the baby attaches or maintains a seal, how milk is flowing, how sucking, swallowing and breathing are coordinated, how comfortable feeding is, how the baby is growing and behaving, whether there are signs of illness or other medical concerns, and whether established feeding patterns or learned compensations may now be contributing. Looking beyond tongue-tie is not about ruling tongue-tie out. It is about making sure that a visible frenulum does not become the explanation before the feeding difficulty itself has been properly understood. Anatomy provides information. Function provides context. References Guóth-Gumberger, M. (2026) ‘Implications of the tongue's anatomy and biomechanics for breastfeeding’, Acta Paediatrica. doi: 10.1111/apa.70555. Harrison, D., Reszel, J., Bueno, M., Sampson, M., Shah, V.S., Taddio, A., Larocque, L. and Turner, L. (2016) ‘Breastfeeding for procedural pain in infants beyond the neonatal period’, Cochrane Database of Systematic Reviews, 10, CD011248. doi: 10.1002/14651858.CD011248.pub2. Office for Health Improvement and Disparities (2026) Infant Feeding Survey in England 2024: Full report. London: Department of Health and Social Care. Available at: https://www.gov.uk/government/statistics/infant-feeding-survey-in-england-2024/infant-feeding-survey-2024-full-report (Accessed: 22 September 2026). O'Shea, J.E., Foster, J.P., O'Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. doi: 10.1002/14651858.CD011065.pub2. Thomas, J. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2024067605. doi: 10.1542/peds.2024-067605. NHS (2025) Congenital heart disease. Available at: https://www.nhs.uk/conditions/congenital-heart-disease/ (Accessed: 22 September 2026).

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

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

Assessment comes first Seeing a frenulum under a baby’s tongue does not, by itself, tell you whether treatment is needed. The important question is how your baby’s tongue and mouth are functioning during feeding, and whether this is affecting breastfeeding, bottle feeding or both. A feeding assessment can look at your baby’s oral function alongside the feeding itself, including attachment, milk transfer, swallowing, suction, comfort and your baby’s ability to maintain an effective feed. It can also help identify other factors that may be contributing to feeding difficulties. If a tongue-tie is identified, there is not one treatment pathway that is right for every family. Some babies and caregivers benefit from conservative management, while others may be considered for infant frenulotomy, also known as tongue-tie division or tongue-tie release. The decision can be made after assessment and discussion of the available options, rather than simply because a frenulum is visible. Conservative management Conservative management is an active approach to supporting feeding without dividing the frenulum. For some families, this may be the preferred option, particularly when feeding difficulties can be addressed through feeding support and other practical measures. Depending on your individual circumstances, support may include: skilled breastfeeding or infant feeding support positioning and attachment adjustments support with milk supply where needed expressing and maintaining milk supply when direct feeding is difficult paced and responsive bottle feeding strategies to support oral function where appropriate addressing factors such as reflux symptoms, colic or nasal congestion when these are present consideration of appropriately qualified bodywork or osteopathic support where this may be helpful as part of wider care These approaches can support feeding and address contributing factors, but they do not divide or remove a restrictive frenulum. If a structural restriction is present, it remains present unless the frenulum is divided. It is also important not to assume that reflux, colic, congestion or other infant behaviours are caused by tongue-tie. Babies can have several overlapping factors affecting feeding, and a good assessment considers the whole feeding picture. You can read more about supporting feeding when a tongue-tie is not divided in Untreated Tongue-Ties. Infant frenulotomy Infant frenulotomy is a procedure in which the lingual frenulum is divided. You may also hear it described as tongue-tie division, tongue-tie release or tongue-tie surgery. For carefully selected infants with documented functional difficulties, frenulotomy may improve some aspects of feeding. However, it is not an instant fix and it does not guarantee that every feeding difficulty will resolve. The evidence is also not equally strong for every outcome. O’Shea et al. (2017) found that frenotomy may reduce maternal nipple pain in breastfeeding, but evidence for improvements in infant feeding outcomes was limited. Other reviews have similarly found uncertainty around many longer-term feeding outcomes (Francis, Krishnaswami and McPheeters, 2015). More recent evidence continues to support a cautious and individualised approach. Dhar et al. (2026) found evidence of a reduction in maternal nipple pain and improvements in maternal perception of breastfeeding. However, evidence for some objective feeding measures was less consistent, particularly when frenotomy was compared with control groups. This means that the decision should consider your baby’s individual feeding difficulties, the assessment findings, the potential benefits and limitations of the procedure, and your family’s priorities. What does the evidence say about breastfeeding? The strongest evidence for frenotomy relates to short-term maternal nipple pain in breastfeeding dyads. For example, Buryk, Bloom and Shope (2011) found that frenotomy was associated with improvements in maternal nipple pain and breastfeeding effectiveness compared with a sham procedure. Emond et al. (2014), however, found no significant improvement in breastfeeding scores at five days, although mothers in the early-frenotomy group were more likely to report improvement in breastfeeding difficulties. The Cochrane review by O’Shea et al. (2017) concluded that frenotomy may reduce breastfeeding mothers' nipple pain in the short term, but there was insufficient evidence to determine whether the procedure improves longer-term breastfeeding outcomes. Dhar et al. (2026) similarly found a substantial reduction in maternal nipple pain and an improvement in maternal perception of breastfeeding, while noting that evidence for other feeding outcomes remains limited or uncertain. This is why a feeding assessment remains important. Nipple pain or difficulty maintaining a latch can have several causes, and dividing a frenulum will not necessarily address every contributing factor. For practical support with bottle feeding, see How to Pace Bottle Feeds: A Calm, Practical Guide. What about bottle feeding? There is less research specifically examining frenotomy for babies who are exclusively bottle fed or who have significant bottle-feeding difficulties. This does not mean that a baby who bottle feeds cannot have functional difficulties associated with tongue movement. It means that the evidence base is smaller, so decisions should be based on an individual assessment rather than assuming that frenulotomy will improve bottle feeding. Bottle feeding can also be affected by teat flow, positioning, pacing, coordination, oral-motor skills, airway or nasal factors and the baby’s individual feeding pattern. A responsive feeding approach can sometimes make a significant difference without surgery. You can read more in How to Pace Bottle Feeds: A Calm, Practical Guide. Do you have to decide quickly? There is no universal deadline by which a tongue-tie must be divided during infancy. Some providers and services have age or weight limits for infant procedures, while others may assess older babies and children. If you are considering frenulotomy, ask the provider you are considering about their own age limits and arrangements. If you are unsure, it is reasonable to take time to understand what is happening with feeding, consider conservative management and discuss the potential benefits and limitations of frenulotomy before making a decision. A visible frenulum does not mean that a procedure has to happen immediately. What should you know about the procedure? Frenulotomy is a surgical procedure and, like any procedure, it has potential risks. These can include: bleeding pain or discomfort infection oral aversion or feeding reluctance injury to nearby structures problems associated with the healing process Serious complications appear to be uncommon, but they cannot be completely excluded. Dhar et al. (2026) reported a pooled adverse-event frequency of approximately 4%, with bleeding the most commonly reported adverse event, although the certainty of this evidence was very low. The provider should explain the potential benefits and risks before you decide whether to proceed, including what you should do if bleeding, feeding difficulties or other concerns occur after the procedure. You can read more about potential complications in YOUR TONGUE-TIE RISKS BLOG. What technique is used? Different techniques are used for infant frenulotomy, including scissors and laser. In the UK, scissors are commonly used for infant tongue-tie division, and NICE guidance describes division using scissors. However, this does not mean that scissors are universally better than laser. Dhar et al. (2026) found that scissors and laser appeared to have comparable effectiveness, although the evidence comparing techniques was limited. There is currently not good evidence to suggest that one technique is universally superior for every baby. The technique is therefore only one part of the decision. The assessment, experience of the practitioner, understanding of infant feeding, informed consent and aftercare arrangements are also important. Aftercare matters too Frenulotomy is not simply a procedure followed by an immediate return to normal feeding. Your baby may need time to adjust to changes in tongue movement and feeding, and the healing process needs to be considered. Your provider should explain what to expect after the procedure, how to recognise problems and who to contact if you have concerns. Feeding support may still be needed after frenulotomy. Improving tongue movement does not automatically mean that a baby immediately develops a new feeding pattern, particularly if they have been compensating for restricted movement for some time. You can read more about this in Beyond the Tongue-Tie Release: Why Aftercare Matters. Choosing a practitioner or service If you are considering frenulotomy, look for a practitioner or service that can explain both the procedure and the alternatives. You may want to ask: Are you professionally registered with an appropriate UK regulator? What training and experience do you have in assessing and treating infants? Will my baby have a feeding assessment as part of the assessment? What other factors could be contributing to the feeding difficulty? What are the potential benefits and limitations of frenulotomy for my baby? What are the risks and possible complications? Which technique do you use and why? What aftercare do you recommend? What happens if my baby has a problem after the procedure? What feeding support is available afterwards? What happens if we decide not to proceed? A practitioner who also has appropriate infant feeding expertise, such as an IBCLC or another suitably qualified infant feeding specialist, may be able to consider the procedure alongside the wider feeding picture. You can also read How Is Tongue-Tie Assessed in Babies Safely? before choosing a practitioner. Neither option is the “easy” option It can be tempting to think of conservative management as doing nothing, or frenulotomy as a quick solution. Neither description reflects the reality for many families. Conservative management can involve ongoing feeding support, repeated adjustments, observation and review. Frenulotomy involves a procedure, a period of healing and potentially further feeding support while your baby adapts. The important question is not which option sounds easiest. It is which information, support and approach fit your baby’s individual feeding assessment and your family’s circumstances. There is also no requirement to choose a procedure simply because a frenulum is visible, and choosing conservative management does not mean that you are ignoring a problem. Equally, choosing frenulotomy does not mean that you have failed to try other approaches. The aim is to understand what is affecting feeding, consider the available evidence and uncertainties, and make an informed decision with appropriate support. References Buryk, M., Bloom, D. and Shope, T. (2011) ‘Efficacy of neonatal release of ankyloglossia: a randomised trial’, Pediatrics, 128(2), pp. e280-e288. doi: 10.1542/peds.2011-0077. Dhar, V., Marghalani, A.A., Amini, H., Brickhouse, T., Caffrey, E., Jayaraman, J., Keels, M.A., Messner, A., Patterson, K.K., Raol, N., Shrestha, P., Stark, C.M., Susarla, H.K. and Thomas, J. (2026) ‘Frenotomy for Ankyloglossia Associated With Feeding Challenges in Infants: Effectiveness, Technique, and Safety—A Systematic Review and Meta-Analysis, Part 2’, Pediatric Dentistry, 48(2), pp. 33E-68E. PMID: 42050812. Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., Sutcliffe, A., Emmett, P. and Salisbury, C. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 99(3), pp. F189-F195. doi: 10.1136/archdischild-2013-305031. Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. doi: 10.1542/peds.2015-0658. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. HealthTech guidance 95 (formerly IPG149). London: NICE. Available at: https://www.nice.org.uk/guidance/htg95/ (Accessed: 18 September 2026). O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. doi: 10.1002/14651858.CD011065.pub2.