What is a Tongue-Tie Restriction?
“Ankyloglossia is a congenital anomaly characterised by an abnormally short lingual frenulum; the tip of the tongue can not be protruded beyond the lower incisor teeth. It varies in degree, from a mild form from which the tongue is bound only by a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise as a result of the inability to suck effectively, causing sore nipples and poor infant weight gain”
(NICE interventional procedures guidance 2005 www.nice.org.uk/guidance/ipg149/chapter/1-guidance?print=true )
“A procedure for excising a frenulum; such as the excision of the lingual frenum from its attachment to the mucoperiosteal covering the alveolar process to correct ankyloglossia.”
(Mosby’s Medical Dictionary 5th edition, Elsevier, 2009)
Some pictures of frenulums and post procedure wounds can be seen here: GALLERY
What is a Tongue-Tie?
Tongue tie is a problem that occurs in babies who have a tight piece of skin between the underside of their tongue and the floor of their mouth.
The medical name for tongue tie is ankyloglossia, and the piece of skin joining the tongue to the base of the mouth is called the lingual frenulum.
It can sometimes affect the baby's feeding, making it hard for them to attach properly to their mother's breast. Tongue tie is a birth defect that affects 3-10% of newborn babies. It is more common in boys than girls.
Normally, the tongue is loosely attached to the base of the mouth with a piece of skin called the lingual frenulum. In babies with tongue tie, this piece of skin is unusually short and tight, restricting the tongues movement.
This prevents the baby from feeding properly and also causes problems for the breastfeeding parent.
To breastfeed successfully, the baby needs to latch on to both breast tissue and nipple, and the baby's tongue needs to cover the lower gum so the nipple is protected from damage.
Infants with a restrictive tongue tie are not able to open their mouths wide enough to latch on to their breastfeeding parent's breast, or form a seal on a teat/dummy/pacifier properly.
Breastfed infants tend to slide off the breast and chomp on the nipple with their gums. This is very painful and the breastfeeding parent's nipples can become sore, with ulcers and bleeding. Some babies frequently feed but inefficiently and get tired, but they soon become hungry and want to feed again.
In some cases, these feeding difficulties mean the baby fails to gain much weight.
Some further details on a Tongue tie restriction, can be found here: TONGUE TIE
You may find this electronic download of a leaflet useful, from the Association of Tongue-Tie Practitioner's:
How may a restrictive tongue-tie affect our feeding experience?
The presence of a tongue tie may not affect your baby at all, however some babies may have restricted tongue movement that may not allow your baby to feed properly.
Affects on Breastfeeding Your baby may:
Have difficulty getting attached to your breast deeply enough
Have difficulty staying attached
Feed for prolonged periods
Be unsettled and not satisfied
Make clicking noises when feeding
Suffer with excess wind, colic or reflux
May dribble milk when feeding from the breast
May choke when feeding
A breastfeeding parent may have:
Low milk supply
Some breastfeeding parents and babies may have some of the above symptoms and problems while others may have them all. Some of the issues may be related to the way your baby is feeding and not the tongue tie. This may be improved by optimising your technique.
Bottle-feeding Your baby with tongue-tie may:-
•Find it difficult to attach to the teat
•Take a long time to feed or feed very quickly
•Drink only small amounts with frequent winding (paced feeding)
•Dribble a lot of milk during feeds
•May not be able to keep a dummy in
•Make clicking noises
•Suffer from excess wind, colic and reflux
Oral Cleanliness/Dental hygiene
When your baby starts to eat solids
Eating food may be a problem as the tongue is important in moving food around the mouth and in swallowing.
When your child starts to talk
Your child's ability to talk is influenced by a variety of factors. Theories may consider a tongue tie may be one of these factors as the movement of the tongue aids in the formation of letters and sounds.
If your child does develop a speech problem they may be referred to a speech and language therapist. If the tongue appears to be causing limited tongue function at this time then the Tongue tie can be cut with the support and expertise of a surgeon or dentist.
Any known risks will be explained on the day of assessment, and although this is not an exhaustive list; it will be disclosed to enable the parent to make an informed decision. Should you agree to these risks then D-Restricted Ltd Consent form will need to be signed by the birth parent. These include:
Most babies do not show signs of pain following the tongue tie division procedure. A few may be 'miserable' for a few days. On rare occasions your baby may particularly unsettled and possibly not feed. Pain relief can be prescribed if this is the case, and in those over 12 weeks old & over 4kg in weight; paracetamol may be considered. Whilst this is stressful for you and baby at the time it shouldn't last too long and is considered temporary. For those babies, it may take up to 48 hours for your baby to settle, you are encouraged to contact me, monitor nappy output/signs of dehydration, and if breastfeeding: protect your supply through expressing. Some calming measures for you to try are found on the Parent's Area of this website or your aftercare booklet given to you at the consultation.
Most babies have no issues with pain following the frenulotomy and some babies do sleep through the procedure too but your infant's response unfortunately can not be predicted.
Other Oral Structures
There is an associated risk that within the vacinity of the mouth I may divide something other than frenulum (such as a nerve or salivary gland). Rest assured, I have not done this before, but the priority treatment would be controlling any blood loss.
Research indicates that one baby in a thousand babies will bleed for longer than expected. The bleeding normally settles with wound compression with no further treatment required or long term effects on your baby. Excess and or prolonged bleeding is rare (1:400), and your practitioner is skilled and equipped for such events. Please remain calm and allow D-Restricted Ltd to contribute to stemming the blood loss. If there is excessive blood loss D-Restricted Ltd may use compression, cold-therapy or a specialist dressings to stem it. The Current bleeding guidance will be adhered to as per the Association of Tongue Tie Practitioners guidelines, and can be accessed here:
There have been reported cases of bleeding which has occurred some time after tongue tie division, usually on the same day when the baby has returned home. If this occurs, the bleeding is usually very light and is triggered by strenuous crying (resulting in the tongue lifting and disturbing the wound) or when the wound is disturbed during feeding, particularly if caught by a bottle teat, dummy, or the tip of a nipple shield (1:300).
At the end of your appointment, D-Restricted Ltd will talk you through what to do in this event should the need arise. This is reitterted in the above guidelines and in the Member's Area too. I recommend these are kept with your child at all times until the wound is completely healed (approximately 2 weeks).
Of 13,000 babies who were followed up post procedure by an ATP study (2022); only one had an infection that needed treating with antibiotics, and continued to breastfeed through this experience. Infection is associated with a fever/high temperature with a wound that is not healing; if you feel that the wound is infected, please see your GP to consider oral antibiotics and review. I am happy to review the wound/view any pictures you can send me as occasionally infection is assumed when it is not. However, I can not diagnose a wound infection based on a picture.
Nursing Strike/ Feeding Aversion/Fussiness
Fussy feeding behaviours are relatively common in infants with a tongue restriction anyway. However, the first 12-48 hours can be particularly unsettling and is usually lined to trapped wind as aerophagia (air intake) is more common in the early learning stages. Supportive techniques will be given to you at your appointment and in your booklet but frequent winding is the key! Also helpful is finger sucking/feeding to calm, (co-)bathing, paracetamol where appropriate and sleep. Occasionally, post procedure, a baby may refuse to feed. D-Restricted Ltd believe this may be because the wound site itself is inflamed (inflammation is 1 of 4 stages of the wound healing process) and contracting to heal. If this happens with your baby there are ways to help your baby feed. The main point to remember is that this is a temporary phase and the most important thing is that your baby gets nutrition and calories until your baby is ready to feed again. Please contact me if you feel this is happening so I can support you.
(sometimes phrased Reattachment/Regrowth/Re-adherence)
In some babies the frenulum may reform . You may notice changes in the way your baby feeds perhaps similar to your previous experience. A further frenulotomy may be considered. Current research indicates that around 3-8% of initial divisions can reform. Please refer to my blog post regarding 'What's the 'deal' with reformation?'.
As with all medical procedures, there are no guarantees. Experience and research suggests there is likely to be an improvement with feeding, and whilst optimum feeding efficiency is the aim, no-one can promise this. However, if following a thorough tongue function & motility assessment I felt that your infant would not gain anything from a frenulotomy procedure, a division would not be the suggested treatment. As an IBCLC (gold standard in lactation care) and an Infant feeding specialist, I would further support you on your feeding journey with a feeding plan to help address any challenges you or your infant may be facing.
Associated Risks to the Tongue-Tie Procedure:
Lip Tie Statement
A lip tie diagnosis and division is a very grey area in UK; USA practitioners divide alongside a tongue tie release, but current research, inclusive of labial and buccal ties does suggest that isn't necessary.
My understanding is that issues with lip-ties are more dentally related and regular dental visits as normal and routine are suggested. A lingual lip-tie is normal anatomy-everybody has one-and they tend to recede as one grows anyway-particularly when adult teeth come through.
However, should you suspect your little one has one, once you do start weaning onto solid foods: be sure to remove any food debris from either side of the tie as held against the gum or tooth may cause decay.
There is also new research I read recently that suggested that even if a lip tie was divided, unless bone was removed then it would usually reform/reattach anyway as the upper lip has not technically got to move in order to allow for a good nutritional intake. It is also a very vascular area so blood loss is generally higher in comparison to most tongue-tie releases. The best profession to get further info on this is the infant’s dentist or an oral surgeon qualified in this area as they can address or signpost any issues. Some oral surgeons and dental surgeons may consider a division should they agree it is impacting the individual's growth.
It is also worth mentioning that many perceived lip tie problems are actually tongue tie related-and once tongue function reaches optimum motility the symptoms alleviate. Sometimes a lip tie can affect the ‘vacuum draw’ of getting breast into a correct breast feeding position but this does not prevent a successful pain-free breastfeed, can be addressed with correct positioning and attachment techniques, and can be subjective.
You may find these helpful: