Tongue-tie (ankyloglossia)

The lingual frenulum is the thin fold of tissue under the tongue that joins it to the floor of the mouth. Everyone has one. In some babies it is shorter or tighter than usual, and that is what is meant by tongue-tie, or ankyloglossia. The main thing for parents to know is this: a short frenulum is not in itself a diagnosis and not in itself a reason to do anything. There is only one question that matters — is it stopping the baby feeding? Plenty of babies with a visibly short frenulum breastfeed beautifully and gain weight, and need no procedure at all.

What it looks like

Tongue-tie is usually noticed when a baby cries or puts their tongue out. The signs are these: the tongue does not lift towards the roof of the mouth, does not come out past the lower lip, and when the baby tries to stick it out the tip is pulled back so that the tongue looks heart-shaped, with a notch in the middle. Sometimes the frenulum is tight right at the tip and obvious at a glance; sometimes it is short nearer the base and much harder to see.

The decision is never made on appearance alone. What is assessed is not the picture but the function: how the baby takes the breast, how they stay on it, how the tongue moves while sucking. A frenulum that looks short but is not getting in the way of feeding needs no treatment, and does not need monitoring either.

When it really does get in the way of feeding

While feeding, the tongue has to lift, extend forwards and move in a wave. If the frenulum prevents that, the picture is usually recognisable — and it shows on both sides at once.

In the baby:

• cannot latch properly on to the breast or the teat and keeps slipping off;
• a clicking sound while sucking, with milk leaking from the corner of the mouth;
• feeds take a very long time and follow one another with almost no gap, as though the baby were hungry all the time;
• tires and falls asleep at the breast before finishing;
• gains weight poorly, or loses it.

In the mother:

• severe pain on feeding that has not settled by the end of the first or second week;
• cracked and damaged nipples;
• the nipple comes out flattened after a feed, with a slanted edge;
• blocked ducts and repeated inflammation of the breast;
• the milk supply falls, because the breast is not being drained properly.

And let us say it plainly: pain while feeding is not something to be endured, and it is not a sign that the mother is "not trying hard enough". It is a signal that something about the feeding is set up wrongly, and it needs sorting out early, before the milk goes.

More often it is the latch, not the tie

This is the most useful idea on the page. Every sign listed above also occurs with no tongue-tie whatsoever: with a poor latch, with an awkward position, with a shallow attachment in which the baby takes only the nipple instead of a mouthful of areola. Latch problems are far commoner than tongue-tie, and they look exactly the same.

So the right order is: help with feeding first, everything else afterwards. A breastfeeding counsellor, a midwife or a doctor watches a whole feed — how the baby is held, how wide the mouth opens, how deeply the breast is taken — and often a single change of position takes the pain away and turns the situation round. If the latch has been sorted out and it still hurts and the baby is still not satisfied, then the frenulum becomes a genuine suspect.

Dividing the tie: what to expect from it

The procedure is called frenotomy and in babies it is straightforward. The fold under the tongue is divided, and it takes a few seconds. In small babies it is usually done without anaesthetic: the frenulum has few nerve endings and few blood vessels, there is almost no bleeding, and the baby can go to the breast straight away, which is also the best comfort. In older children and adults it is done under anaesthetic.

What is worth understanding beforehand:

• It does not help everyone. In some pairs the pain goes and feeding settles within days; in others the improvement is partial; in some nothing changes at all, which means the frenulum was never the problem.
• The procedure alone is not enough. A divided frenulum does not teach a baby to feed differently. Help with attachment is needed before it and, above all, after it; without that the gain is lost and the family is back where it started.
• Doing it "just in case", with no feeding difficulty, serves no purpose.
• Be particularly wary of private offers to laser-divide a "posterior tie" or an upper lip tie in children who are feeding without difficulty. No benefit has been shown, and the child is put through a procedure regardless.

Older children, speech and adults

Parents are often told that a tongue-tie will stop a child talking or make them lisp. In reality the link with speech is far weaker than commonly believed: the great majority of children with a short frenulum speak normally, and when a sound will not come the cause usually lies elsewhere. Division for speech reasons is rarely indicated, and only after a speech and language therapist has worked out exactly what is not working and whether it has anything to do with how the tongue moves.

Sometimes a short frenulum causes more everyday inconveniences: licking the lips or an ice cream is awkward, the tongue cannot reach food left around the teeth so oral hygiene suffers, playing a wind instrument or kissing is uncomfortable. These things are discussed with a dentist; in older children and adults the procedure is done for a specific reason, not because the frenulum happens to be short.

When to seek help

It is worth being seen if feeding is hard going, if it hurts you, or simply if you are unsure: an assessment costs nothing, and a week of failed feeds costs a great deal.

Do not wait — seek help the same day — if your baby:

• is not gaining weight or is losing it, or has not regained the birth weight by the end of the second week;
• is wetting noticeably fewer nappies, the urine is dark, the mouth is dry;
• is listless, hard to wake for feeds, and has stopped asking to be fed;
• is becoming increasingly yellow;
• after a tongue-tie division, bleeds and does not stop, refuses the breast, or develops a fever.

A mother should seek help if a red, hardened area appears in the breast, with pain, fever and shivering: those are signs of inflammation that is treated rather than waited out.

Online consultation

A remote appointment is useful precisely at the stage when it is unclear what is going on. The doctor will ask in detail how feeds are going, how long they last, whether there is clicking and milk leaking, how weight gain and wet nappies are doing, and will ask to see how the baby latches on — that shows up well enough on video. Often that review alone is enough to correct the position and the latch and to work out whether an in-person examination is needed at all. Online is also a good place to consider whether to accept a procedure that has been offered, what to do afterwards, and how to protect the milk supply while feeding is being sorted out. What can only be done in person is examining the baby's mouth, assessing how the tongue moves, and carrying out the division itself.

This material is for information only and does not replace medical advice.