by Dr Rachel Wakelin, General Practitioner BSc BM MSc FRCGP

I ended up with cracked nipples, both sides, both very sore….Sometimes it can take me up to half a hour to get the courage to get him on ’cause it hurts.

quote from Kyra, Edmunds J.E. et al (2013) J Hum Lact.

We went and got his tongue cut . . . and then pretty much from then everything has been fine. It doesn’t hurt like it did before . . . and it just feels normal. . . . My nipples have started to heal. . . . I think we are getting a better bond now because I am not scared of him.

quote from Debbie, Edmunds J.E. et al (2013) J Hum Lact.

Key Points

  • Tongue-tie is common and can impact feeding
  • Timely support of feeding is crucial to enable establishment of feeding
  • Symptoms of breast or feeding problems may be more apparent than clinical appearance
  • Signpost mothers to seek expert feeding and tongue-tie advice
  • NICE and research evidence support frenulotomy for tongue-tie if conservative measures have failed

Introduction and NICE Guidelines

Prevalence of tongue-tie is between 0.2 and 10.7%1-3. It can be defined as an embryological remnant beneath the tongue that restricts movement and can impact breastfeeding4. A tongue-tie may be obvious based on the appearance, however posterior ties can be less obvious to the untrained eye. Seven systematic reviews1-3, 5-8 and a National Institute of Clinical Evidence guidelinereport that a tongue-tie release (frenulotomy) can be beneficial for breastfeeding10, 11 but there is still a diversity of opinion on the diagnosis and delay in treatment in many cases12.  Many symptoms linked with tongue-tie parallel reasons identified in the UK Breast Feeding Survey for early breastfeeding cessation13.

Symptoms Linked with Tongue-Tie14IMG_1815

  • Nipple pain and trauma
  • Mastitis
  • Low milk supply
  • Latch problems
  • Nipple biting
  • Frequent or lengthy feed
  • Clicking noises during feeds
  • Dribbling and loss of latch during feeds
  • Colic, reflux, wind or hiccoughs
  • Poor weight gain

What to do?

Ask about breastfeeding symptoms at the 6-week check when a mother presents with breast or nipple problems, or a child with poor weight gain, colic or reflux.

Consider looking in the babies mouth to look for an obvious tongue-tie. However because diagnosis can be difficult refer on for the consideration of diagnosis to a midwife, health visitor, lactation consultant or tongue-tie practitioner with expertise in diagnosis.


If a baby has been diagnosed with tongue-tie NICE recommend conservative management initially. Advise mothers to seek lactation support and guidance as to whether they need a tongue-tie release. This is usually done by a frenulotomy; a simple procedure which involves snipping the tongue with sharp, round scissors, no local anaesthetic is used and bleeding is stopped by allowing the baby to feed, which compresses the wound15.  Referral pathways vary; procedures are performed by specifically trained ENT/paediatric surgeons, midwives or health visitors (see our page on ‘Breastfeeding Support‘ for more information on tongue-tie practitioners).


Private Practice

Frenulotomies can also be performed by tongue-tie practitioners in private practice. There are BMA guidelines16 on the best approach to discussing private care with patients. A list of practitioners can be found on the website of the Association of Tongue-Tie Practitioners.

Research into Tongue-Tie

This is a challenging area to research, because randomised controlled trails will not always suit investigation into infant feeding. The research that has been done is broad ranging, with diverse outcome measures used and so firm conclusions are hard to make.

Evidence –Effect on Mothers

There is evidence that infants have a difficult journey to diagnosis and mothers can have a tough time feeding an infant with tongue-tie and describe an ‘anticipatory dread’ prior to feeding17.

Evidence – Tongue-Tie Impact

This is supported by three systematic reviews demonstrating breastfeeding difficulties for infants and mothers3, 8, 18; although syntheses of data was not possible due to the huge diversity in outcome measures. Two subsequent studies add to this data19, 20.

Evidence – Frenulotomy Efficacy

Seven systematic reviews1-3, 5-8 have been undertaken in this area. Five reviews seem clear that there is evidence that frenulotomy can improve breastfeeding difficulties in infants with tongue-tie2, 5-7. Two reviews1, 3 draw more tentative conclusions that there is a small body of evidence to suggest that frenulotomy can offer improvement and confidence in that evidence is low. The authors of the final review8, due to inability to make comparisons between studies, felt they could not draw conclusions to resolve controversy in this area.

Further Information 

Association of Tongue-Tie Practitioners The organisation for tongue-tie dividers. The website includes a directory of NHS and private practitioners in the UK and information for parents and health care professionals.

NICE Guidelines IPG149: Division of Ankyloglossia (Tongue-Tie) for Breastfeeding

Unicef UK Babyfriendly Initiative: Overcoming Breastfeeding Problems- Tongue-Tie Includes advice for health care professionals on how to write a referral for tongue-tie assessment and a contact to enquire about training in tongue-tie division.


  1. Francis D, Krishnaswami S, McPheeters M. Treatment of Ankyloglossia and Breastfeeding Outcomes: A Systematic Review. Pediatrics. 2015;135(6):e1458-e1466.
  2. Power R, Murphy J. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Archives of Disease in Childhood. 2014;100(5):489-494.
  3. Segal L, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review. Canadian Family Physician. 2007;53(7):1027-1033
  4. The International Affiliation of Tongue-tie Professionals. Definition of tongue-tie 2015
  5. Finigan V, Long A. The effectiveness of frenulotomy on infant-feeding outcomes: A systematic review. Evidence Based Midwifery. 2013;11(2):5.
  6. Ito Y. Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia?. Pediatrics International. 2014;56(4):497-505.
  7. Webb A, Hao W, Hong P. The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology. 2013;77(5):635-646.
  8. Suter V, Bornstein M. Ankyloglossia: Facts and Myths in Diagnosis and Treatment. Journal of Periodontology. 2009;80(8):1204-1219.
  9. National Institute for Health and Clinical Excellence. IPG149 Division of ankyloglossia (tongue tie) for breastfeeding – information for the public.  London 2015. p. 12.
  10. Brinkmann S, Reilly S, Meara J. Management of tongue-tie in children: A survey of paediatric surgeons in Australia. Journal of Paediatrics and Child Health. 2004;40(11):600-605.
  11. Messner A, Lalakea M. Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology. 2000;54(2-3):123-131.
  12. Boffey D. Concern over delays to treatment of babies suffering from tongue-tie:; 2014
  13. McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ. Infant Feeding Survey 2010. 2012.
  14. Practitioners AoT-T. Tongue-tie Information and Infant Feeding Issues. 2013
  15. Association of Tongue-Tie Practitioners. Tongue-Tie Leaflet Online 2014
  16. British Medical Association. The interface between NHS and private treatment: a practical guide for doctors in England,Wales and Northern Ireland. Guidance from the BMA Ethics Department. London2009. p. 14.
  17. Edmunds J, Fulbrook P, Miles S. Understanding the Experiences of Mothers Who Are Breastfeeding an Infant with Tongue-Tie. Journal of Human Lactation. 2013;29(2):190-195.
  18. Edmunds J, Miles SC, Fulbrook P. Tongue-tie and breastfeeding: a review of the literature. Breastfeeding Review. 2011;19(1):19-26.
  19. Puapornpong P, Raungrongmorakot K, Mahasitthiwat V, Ketsuwan S. Comparisons of the latching on between newborns with tongue-tie and normal newborns. Journal of the Medical Association of Thailand. 2014;97(3):255-9.
  20. Ngerncham S, Laohapensang M, Wongvisutdhi T, Ritjaroen Y, Painpichan N, Hakularb P, et al. Lingual frenulum and effect on breastfeeding in Thai newborn infants. Paediatrics And International Child Health. 2013;33(2):86-90

Published April 2017