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Sometimes parents ask about having a tongue tie division and vitamin K. This article is a useful discussion of the issues. It gives you a context to explain why this is a concern.

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I am often asked about vitamin K and tongue tie division.

In one example, Cathy wrote, "Sara, what are your thoughts on tongue tie division with baby who hasn't had vit k? If mother has made informed decision, can a medical professional decline to do division?"

Well, as is so often the case, the answer to this does depend a bit on where you are in the world. And many other factors affect the availability of health care, as we have learned from the measures taken in an attempt to reduce the spread of the SARS-CoV-2 virus.

But, as I wrote in my book, Vitamin K and the Newborn, I am aware that, "many of the people who perform tongue-tie division surgery won't carry this out on babies under 12 weeks unless the baby has either received IM vitamin K or it can be demonstrated via a blood test that the baby has an adequate blood clotting result."

A tricky issue
This is a really tricky situation in which a few different issues are tangled up.

Parents have the right to decline prophylactic (preventative) treatments such as vitamin K.

But they do not necessarily have the right to demand treatments, such as tongue tie.

That's especially the case with treatments considered to be elective. (Elective means that they are not immediately necessary in order to preserve life.)

And it's even more the case if a baby is felt to be more at risk from the procedure.
The duty of care
Here's why this is a thorny issue. All procedures carry risk and possible side effects. Professionals should discuss the risks and benefits of a procedure with you. Then you can decide if it's something you want or not. That's a cornerstone of good practice and it's there so that people can make informed decisions.

But it's not just up to the person themselves.

Professionals have an obligation to avoid doing things that are dangerous, generally unless they are life-saving.

This can put them in a really tricky position when people ask for elective procedures in circumstances that they think are too risky.

A professional is responsible for their own practice, and can be punished if they do not follow appropriate law and codes.
Why some professionals decline
Many professionals consider that a baby who hasn't received vitamin K is at increased risk of bleeding during elective procedures. (Another example of an elective procedure done in some countries where babies are expected to have been given vitamin K is circumcision).

Some consider that the risk is more than they feel comfortable with.

As a professional, they are obliged to follow their code of conduct. And that's why, in some situations, a professional can decline to perform a procedure.

It's complicated, though. It is sometimes possible to find a practitioner (sometimes privately) who is willing to perform tongue tie in a baby who hasn't had vitamin K. Some will perform tongue tie surgery on babies who have not received vitamin K if parents sign a consent form. Sometimes, health systems manage to avoid giving an outright 'no' to this request by finding a way to delay the surgery.

This is such a tricky area, and I know that opinions are divided (no pun intended). One reason that this is such a tricky subject is because we all have different perceptions about two important factors: risk and responsibility.

As I also discuss in Vitamin K and the Newborn, the chance of a baby having a bleed is low, but the consequences can be very serious. So this is not an easy decision.

Timing may be a key factor here. Parents in some areas may be able to request a clotting screen in order to demonstrate that the baby can adequately clot their blood. Parents may need to pay for this privately. But it is also, as I said at the outset, a bit of a postcode lottery. So it's worth getting in touch with local practitioners and/or other birth workers to find out what the situation is in your area.

Books to help you become informed and make the decisions that are right for you...

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Vitamin K and tongue tie division - Dr Sara Wickham

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What happens when parents want a tongue tie division but the baby hasn't had vitamin K? Can professionals decline to do this? What are the issues?

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Basic information on Vitamin K and TT division

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Basic information on Vitamin K and TT division

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Page 15 in Sarah Oakley's booklet also has a snippet that you could direct parents to.

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This training does not cover the evidence for tongue tie division because it focusses on the practicalities of supporting parents. However here are some historic papers which may be of interest.

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This 2019 observational study in Brazil found an incidence of 9% for tongue tie. It's not clear from the abstract what the criteria were for presence/absence of tongue tie

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NCT BFC and lactation consultant Jill Shepherd has recorded a podcast on tongue tie which is really worth a listen! Loads of info, plus check out the reference list on the podcast page

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Oral Anomalies In Newborns: An Observational Cross-Sectional Study. de Oliveira AJ, Duarte DA, Diniz M 2018 https://www.researchgate.net/publication/339688830_Oral_Anomalies_In_Newborns_An_Observational_Cross-Sectional_Study

Association of Tongue Tie Practitioners https://www.tongue-tie.org.uk/

Jill Shepherd's website http://www.horshambreastfeeding.co.uk/

Priya Mistry: Tongue Tie, Airway and TMJ Disorders https://m.youtube.com/watch?v=ezmCHs2rf9s&t=9s

Paced bottle feeding video https://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/giving-a-breastfed-baby-their-first-bottle

Book: Why Tongue Tie Matters, by Sarah Oakley. Available from pinterandmartin.com

HELPLINES:

NCT: 0300 3300 700 option 1 https://www.nct.org.uk/baby-toddler/feeding/early-days/support-breastfeeding-or-bottle-feeding-our-infant-feeding-line

Association of Breastfeeding Mothers https://abm.me.uk/get-breastfeeding-support/ Breastfeeding Network https://www.breastfeedingnetwork.org.uk/breastfeeding-support/ La Leche League https://www.laleche.org.uk/get-support/

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‎The Breastfeeding Show: Tongue Tie on Apple Podcasts

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University of Southampton nhs leaflet giving guidance to parents on how to do TT exercises. These seem gentle, but I don't know of evidence for or against.

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Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in Infants? - Association of Tongue-tie Practitioners

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Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in Infants? Slothouber Galbreath et al, JHL, Volume 30, Number 4, page 501, November 2014 Dear Editor Re: Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in I…

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useful article.

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If baby's lip does not flange when feeding, stays straight or even curls inwards - it suggests lip tie.

Whilst Catherine often writes about tongue tie, I was interested to hear whether she felt lip ties were a significant cause of breastfeeding issues. She replied:

"I think the upper lip frenulum is infrequently an issue when breastfeeding. I am concerned that the term "lip tie" causes parents to be overly concerned about this issue and could increase doctors' skepticism of frenotomy."

Add together tight grip of the lips + moving = friction blister on upper lip/babies slipping off the breast as their own suck pushes them backwards.

Now let's consider feeding.

According to orthodontist, Glenn Carty:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth.

A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth".

Furthermore, it's well recognised they may have a gap:

"The permanent maxillary central incisors are flared laterally at this time because the unerupted lateral incisors constrain the roots of the centrals. The median diastema, which results from this flaring is normal and often is called the "ugly duckling stage" of the developing dentition. As the permanent maxillary lateral incisors and canines erupt, pressure is exerted medially, causing the space to close and the frenum to atrophy." (4)

"In some cases the series of events just described does not occur." (4)

In the UK it is common to treat an upper frenum around the ages of 10 or 11 if it has not regressed and is impacting on alignment of the upper teeth, a brace may also be used at this time to assist with closure. And I think this reflects healthcare typically in the UK, and why treating upper lip frenums is much less popular here. As a tax funded system, we treat something if and when it's a problem.

My understanding of US medicine is that it more heavily focusses on potential prevention. Lip attachment appears to be removed at times because they might cause a problem later, or they might be causing a problem now, and the parents travelled across 8 states for four days to get here, and as we understand it we don't "need" an upper frenum, so lets remove them just in case; it's only a frenum! And I'm sure there are both pros and cons to this approach too.

I also collected photographs from people kind enough to share of untreated upper lips and the normal regression that occurs:

Despite treatment 2 1/2 years ago for the child on the right, the gap remains and looks remarkably similar to his sibling's pictured bottom left.

This isn't surprising. To give you a potted history of the information I've gleaned about upper ties and diastema, and then a link to where you can read the full caboodle if you fancy.

In 1907 it was first suggested that a thick labial frenum was the cause of diastema. By the middle 1900s, the it was believed to be correlation rather than a cause. They found gaps without frenums, frenums without gaps, and several studies found no associations between the size of the gap and the frenum. They also discovered that in some cases, the bone had not formed correctly - and that in such cases an abnormal frenulum was the result. Ie potentialy the gap caused or correlated with an abnormal frenum rather than the reverse.

"A V-shaped bony cleft develops between two central incisors, and an "abnormal" frenum attachment usually results.16. Transseptal fibers fail to proliferate across the midline cleft, and the space may never close.1 ' 18"" (4)

In short during conception, a tiny cleft forms in the bone, holding the teeth apart.

They even studied the effect of frenectomy on diastemas, and found "that although closure progressed more rapidly in the frenectomized group than in the unoperated group, there was no difference in the final results after 10 years. These results intimate that frena may exert passive resisting mesial pressure, but are not an important etiologic factor in midline diastemas.22" (4)

Thus we absolutely cannot say that ties cause gaps, or treating a tie will resolve or prevent one.

The next question logically therefore is does potential early closure of a gap affect placement of other teeth, and if so in a negative or positive way?

This image on the left was sent to me by a dentist who got it third hand, so I'm not sure who it belongs to in terms of crediting/using here, there was no copyright notice displayed - therefore if it's yours please get in touch! (I have tried reverse image searches etc to no avail)

You can see the gap quickly closes post revision.

The UK dentists I've spoken to all seem unsure and say they would rather wait until clear and obvious reasons for immediate intervention. But then very few here regularly perform frenectomies on babies, and so have little experience.

Presumably the American dentists treating upper frenums don't notice an increase in problems? But I haven't seen any written material addressing this, if you have please share :)

The issue of decay to infant teeth also arises in the case of a tight frenulum, which again seems to split dentists (even those who treat). As one pointed out, if you know there's a frenum, simply wipe up each side instead of over the top as it's stray food particles than cause the problem - so make sure you remove them. Others don't feel that is sufficient to prevent problems. Reducing bottle use can also reduce the impact of milk plus food together, which is a known risk in terms of decay; brushing teeth after the last feed if using formula is also advised.

Any other risks?
Without studies, how can we know? An ENT here in the UK who would treat upper frenum with a "half snip" only if the tongue tie didn't improve things, and only if a midwife or lactation consultant confirmed they believed it to be the cause (I speak past tense as he's now emigrated), used to ask parents to sign a document stating that there may be potential unforseen consequences, without research we cannot be sure.

He also theorised a risk of removing the upper frenum, may be that without the "anchor", the lip would then lift too high exposing gum. I was assured by two different providers this absolutely wasn't the case, and in fact the opposite was true - a tight frenum pulled the lip.

As soon as I published this blog today, someone got in touch to say this is exactly what both she and her dentist felt happened to her, and she sent me the photo you can see on the left hand side. Her upper frenum which extended onto the palate was removed at 10 years of age due to a huge gap. As you can see this closed, but she states that whilst she does have long gums, her lip didn't lift to reveal them to this degree before surgery. She has promised to dig me out some childhood pictures, and so I will update then.

I also believe there are increased risks to treating both areas at the same time. For a baby with tongue tie, compensating with the lips as discussed, to make both the tongue and lip sore can be a step too far. Remember they have likely already found feeding difficult for sometimes months.

Helen Marshall IBCLC said:

"I am seeing a high incidence of breast refusal. Usually just for 24-48 hours but that is significant to the mother who was exclusively breastfeeding and is now having to bottle or cup etc"

Discussion:

In the UK we tend to like regulations, guidance and studies. We have that in the form of NICE guidelines for tongue tie treatment, which confirms anaesthesia is not required, and has evaluate the risks benefits involved. We don't have this for frenectomy, we don't even have any studies confirming if and when it helps feeding.

The other problem appears to be that both upper lips and tongue ties are treated at the same time - so how on earth do we establish which intervention helped? At suggestion they could potentially study this I was advised it was unethical to do so, as it would mean leaving a baby with a known tongue/lip tie to test the theory. Can't say I'm entirely convinced by that logic.

Undoubtedly as I said in the introduction to this article, there are times the attachment is restrictive. I've seen several so thick and tight the lip is unable to function properly - and who wants to spend their life with their top lip stuck down? But these, in terms of feeding problems, appear to be a small percentage of babies.

What's more, if we're not quite right with the diagnostic criteria, could we potentially miss those that are restrictive? My son (8) for example has a thin upper frenum, well away from his teeth and with apparently normal "flangability". However he has for several years intermittently told me it's "too tight", asked if they can "cut it off", struggled to clean a spoon for a long time, and I think has reduced movement when talking.

If you feel up inside his lip when it's relaxed - that's the point at which the frenum feels tight. (I should add he does have a posterior tongue tie that wasn't diagnosed during infancy)

In short we know some, we are still learning, but there's a lot left to learn. In my opinion anyone who talks in certainties about lip ties can only be speaking anecdotally, because there are no controlled studies. Whereas tongue tie and the impact on infant feeding has been explored over decades, we have a hole where the lip tie studies need to be.

Yes it's a relatively minor intervention in the scheme of things, if there are clear issues the preservation of feeding is of course paramount, due to the health implications of early cessation of breastfeeding. But if we are talking "every baby with a tongue tie has a lip tie" (as some webgroups claim), don't we need guidance?

Does the area need numbing? What is appropriate pain relief? If you're into complementary medicine, an

acupuncturist once tol me the upper lip frenum is a key point as it apparently sits on a junction of two significant channels. This might mean more to you than me, but there's a little more information here.

It's a minefield for parents at the moment, in an age of trying to seek out answers via the internet, and simply wanting to resolve their baby's issues - they're vulnerable to the next quick fix or magic wand. I get calls three days after a tongue tie treatment saying "it hasn't worked and should we now treat the upper lip?". The reality is that there are no instant solutions for many babies, even once the tongue is free - being a muscle it often needs to develop strength to consistently perform well, particularly with posterior ties. You wouldn't get a cast removed from your leg and expect to run a marathon 24 hours later. Similarly there is no benefit to patiently waiting weeks if baby has another reason they're not feeding better, such as a supply dip, a stiff neck or reattachment.

This is why working closely with your lactation consultant or breastfeeding counsellor who specialises in tongue tie is key for some. One look at the internet chatter tells us that removing a piece of skin before pushing parents out the door 10 minutes later simply isn't enough for many. Babies and their barriers to feeding are more than bits of skin, but that's a blog for another day....

Note: I got 3/4 of the way through this blog, when Dr Ghaheri posted this great article. Worth a read as although there is some crossover, it's great to get another perspective.

References:
1. http://doctorspiller.com/Childrens_Dentistry/Childrens_Dentistry.htm#adult_eruption_schedule
2. Tethered Labial Frenum With Midline Diastema, SANJEEV TULI, MD, DEEPA SUNKARI, MD, DALLAS McKAY, MD, MARIA KELLY, MD, and SONAL TULI, MD, University of Florida, Gainesville
2. Department of Pedodontics, University of Umeå, Sweden.International Journal of Paediatric Dentistry (Impact Factor: 0.92). 07/1994; 4(2):67-73. DOI: 10.1111/j.1365-263X.1994.tb00107.x

3. An overview of frenal attachments, M Priyanka, R Sruthi, T Ramakrishnan, Pamela Emmadi, N Ambalavanan, Department of Periodontology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India, Year : 2013 | Volume : 17 | Issue : 1 | Page : 12-15
4. The midline diastema: a review of its etiology and treatment Wen-Jeng Huang, DDS Curtis J. Creath, DMD, MS, American Academy of Paediatrics, Pediatric Dentistry - 17:3, 199

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If baby's lip does not flange when feeding, stays straight or even curls inwards - it suggests lip tie. Whilst Catherine often writes about tongue tie, I was interested to hear whether she felt lip ties were a significant cause of breastfeeding issues. She replied: "I think the upper lip frenulum is infrequently an issue when breastfeeding.

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Useful information for us as well as to share with parents who want more detail. Written by Sarah Oakley LC, this booklet covers most issues in detail. It is very much rooted in practice and the parent's experience and includes detailed descriptions of every stage in the TT journey.

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The National Institute of Clinical Excellence has approved the division of tongue ties where there is an impact on breastfeeding. You can read the full guidance here.

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Evidence-based recommendations on division of ankyloglossia (tongue-tie) for breastfeeding. This involves cutting through the fold of skin using sharp, blunt-ended scissors so the baby can feed.

Is this guidance up to date?

Next review: this guidance will be reviewed if there is new evidence or safety concerns.

Guidance development process
How we develop NICE interventional procedures guidance
Coding and clinical classification codes for this guidance.

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Division of ankyloglossia (tongue-tie) for breastfeeding

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Evidence-based recommendations on division of ankyloglossia (tongue-tie) for breastfeeding. This involves cutting through the fold of skin using sharp, blunt-ended scissors so the baby can feed

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The NCT page on Tongue tie

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What is a tongue-tie (ankyloglossia)?

Most people have a frenulum - a piece of tissue under their tongue that stretches from the underside of the tongue to the floor of the mouth. Tongue-tie occurs if the frenulum either extends forwards towards the tip of the tongue, is attached close to the lower gum, or is short and tight so it interferes with normal tongue movement (Oakley, 2021).

What problems does tongue-tie cause for babies?

If a baby has a tongue-tie, they may not be able to extend or lift their tongue or move it from side to side. Some will be able to lift the sides, but not the tip (v-shaped tongue). Some will be unable to lift the posterior of the tongue (bowl-shaped tongue). In babies where they frenulum extends all the way to the tip, the tongue may look heart-shaped.

Tongue-tie can affect both breastfeeding and bottle-feeding. For some babies, the effects will be quite mild. For others, tongue-tie can make feeding extremely challenging or even impossible.

In order to breastfeed, a baby needs to be able to open their mouth wide, extend their tongue over their bottom lip and scoop the breast into their mouth. Then the tongue needs to massage the breast in a wave-like motion to remove milk from the breast (Oakley, 2021).

If your baby has a tongue-tie and you are breastfeeding, you might experience one or more of the following in your baby:

difficulty in latching

difficulty in maintaining a latch, with your baby frequently coming off the breast or slipping back to the nipple

a shallow latch

clamping down on the breast

clicking noises while feeding

unsettled behaviour during feeds

frequent or long feeds

poor weight gain or excessive early weight loss

colic/wind/hiccups/reflux.

If you are breastfeeding your baby and they have tongue-tie, you might find your nipples are sore and appear squashed after a feed, often appearing ridged, lipstick-shaped, flattened or blanched. If your baby isn't draining your breasts adequately, this can lead to engorgement, blocked ducts and mastitis. It can also have a negative effect on your milk supply. Feeds which are long or frequent can be very tiring (NHS, 2020; Oakley, 2021).

If you are bottle-feeding your baby, you might notice one or more of the following - your baby:

is very slow to take a bottle

chomps on the teat

needs to be fed very often in order to get enough milk

dribbles a lot during feeds

tends to push the bottle teat out

gags on feeds even when you slow the feed down

can only manage a teat that has a very slow flow.

(Oakley, 2021)

How is tongue-tie diagnosed?

Can I tell if my baby has a tongue-tie?

If you look in your baby's mouth, you might be able to see if they:

are unable to extend their tongue fully

have a tongue with a heart-shaped appearance at the tip

have difficulty lifting their tongue or moving it from side to side.

Tongue-tie is not just about how your baby's tongue looks. A tongue can look completely normal to an untrained eye yet still cause substantial problems with feeding (Young, 2011).

A tongue-tie is diagnosed by the baby's tongue function too - what they can do with their tongue. It can only be diagnosed by a qualified tongue-tie practitioner (NHS, 2020).

Tongue-tie types

Tongue-ties can be described as anterior (where the frenulum extends towards the front of the tongue) or posterior (towards the back of the mouth).

Tongue-ties might also be described using a percentage or a number (type I, II, III and IV). This percentage or number describes how far along the underside of the tongue the frenulum comes. So 100%, or type I, would indicate that the frenulum comes all the way to the front of the tongue.

A posterior tongue-tie, which may be described as a 10% tongue-tie, can restrict tongue function just as much as an anterior one. That means these anatomical descriptions of how the tongue looks don't always relate to how severely a tongue-tie will affect tongue function and your baby's feeding (Oakley, 2021).

Tongue-tie diagnosis

Some babies have a visible frenulum that doesn't cause problems with feeding (UNICEF, no date). Tongue-tie shares many of the symptoms of other breastfeeding problems, so it's not always easy to determine whether these problems are caused by a tongue-tie or something else.

A full feeding assessment should be done before or as part of a tongue-tie assessment (Oakley, 2021). If you and/or your baby are experiencing feeding difficulties, a feeding assessment and some breastfeeding support from a breastfeeding counsellor or trained breastfeeding professional is recommended. Support to improve your baby's attachment to the breast may resolve the problem (UNICEF, no date).

A baby's inability to open their mouth widely and extend their tongue may also be caused by tension around the mouth and neck, resulting from birth tensions or interventions during labour. This might be resolved by manual therapy, such as osteopathy or chiropractic from a registered practitioner (ATP, no date; Oakley, 2021).

If the breastfeeding professional (breastfeeding counsellor, midwife or health visitor) suspects your baby has a tongue-tie, they will refer you to a local tongue-tie practitioner. Tongue-tie practitioners will do a formal assessment of tongue-tie based on how the tongue functions as well as how it looks (e.g. the Hazelbaker Assessment Tool for Lingual Frenulum Function). Most midwives and health visitors are not tongue-tie practitioners so are unable to make a diagnosis of tongue-tie themselves.

Tongue-tie treatment

What is tongue-tie division?

Your baby could have a tongue-tie division, which can release their tongue so it can move more freely. This involves cutting the frenulum (NICE, 2005).

Tongue-tie division is a safe procedure that can improve the breastfeeding problems that tongue-tie causes (NICE, 2005).

Does tongue-tie division hurt?

Tongue-tie division procedures are very quick and simple and are thought to be almost painless (NICE, 2005).

Does tongue-tie division resolve feeding problems?

Most parents say their baby's feeding improves after a tongue-tie division and many find it resolves the problem completely (Buryk et al, 2011; Berry et al, 2012). But a few babies do continue to have feeding difficulties even after a tongue-tie division.

Do I need to get my baby's tongue-tie treated?

The decision on whether to have a tongue-tie divided is a personal one and different parents will make different decisions. Every tongue-tie is different too and the range of issues it causes can vary from very mild to severe. So how much the tongue-tie is affecting feeding and your life with your baby might influence your decision.

You might find it helpful to talk things through with an NCT breastfeeding counsellor too. They can help you explore your thoughts and feelings plus find ways of coping if you decide not to have the procedure done.

What else might help with feeding difficulties due to tongue-tie?

For some babies, it may be possible to improve feeding without having a tongue-tie division.

If babies are fed in a laid back position, they are more relaxed, can open their mouth wider and get a bigger mouthful of breast. But some babies are unable to extend their tongue enough to scoop the breast into their mouth, so this position doesn't make feeding easier. A side-lying position or koala hold might also help.

Babies can also be helped by using an 'exaggerated latch'. This is where you hold your baby close to but below the breast, and use your forefinger to tilt your nipple upwards. That way, when your baby tips their head back and is brought into the breast, your nipple can be flipped towards the back of their mouth (Oakley, 2021).

Babies who are bottle-fed might find feeds easier if paced bottle feeding techniques are used. Occasionally, finger feeding can be a more comfortable option than using a bottle (Genna, 2013). A tongue-tie can make it difficult for babies to form a seal around the bottle teat. A high palate, often associated with a tongue-tie, can trigger the baby's gag reflex. Shorter, wedge-shaped or flatter teats may be easier for babies with a tongue-tie to drink from (Oakley, 2021).

How can I find tongue-tie division services near me?

Only registered healthcare professionals who have received proper training in tongue-tie division should perform this procedure. In many areas, the NHS provides a tongue-tie division service. But provision varies across the country and parents in some areas have to travel long distances to reach a tongue-tie division service.

It can be even harder to find a tongue-tie division service when a baby is having problems bottle-feeding. Unfortunately, some areas might have no service available (Wise, 2015).

The National Institute for Health and Care Excellence - also known as NICE - supports considering tongue-tie division. Yet there is no common agreement among tongue-tie dividers on how to carry out the procedure or how far the membrane should be divided (NICE, 2005). This means the service different health professionals offer varies.

Online, you can see a directory of both NHS and private tongue-tie practitioners on the Association of Tongue-tie Practitioners (ATP) website.

What can I expect after my baby's tongue-tie division?

Babies are often unsettled in the first day or two after a tongue-tie division and might need more cuddles and nurturing. After the procedure, you'll probably see a white patch under your baby's tongue; this takes 24 to 48 hours to heal but it won't bother your baby (UNICEF, no date).

Do I need to do anything after the tongue-tie division?

Some tongue-tie practitioners recommend some tongue exercises or wound massage after a tongue-tie division. The exercises involve encouraging the baby to move their tongue through finger sucking and tongue-poking games. Massaging the wound with a clean finger may help prevent the tongue division knitting together and re-forming but there is no evidence to suggest that this is safe or effective (Oakley, 2021).

Will my baby's feeding improve after their tongue-tie division?

Parents often expect that feeding will improve immediately after a tongue-tie division.

Feeding can be more difficult for the first day or two after a tongue-tie division because it takes time for your baby to adjust to their new, freely-moving tongue (Oakley, 2021).

Some babies might need further support even after a tongue-tie division. If things have not improved after a few days, you might find it helpful to get extra support to improve feeding - see below.
This page was last reviewed in March 2022.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby

Attending a Baby Cafe or other breastfeeding support drop-in can be a good way to access support with feeding your baby. You may also find other parents there whose babies have had a tongue-tie.

Pictures of babies with tongue-tie can be found on Catherine Genna's website.

The Association of Tongue Tie Practitioners has a list of locations where tongue tie can be divided.

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Tongue-tie in babies | Baby & toddler, Feeding articles & support | NCT

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https://www.tongue-tie.org.uk/Tongue-tie (ankyloglossia) in babies can affect both breastfeeding and bottle-feeding. Here we explain about tongue-tie symptoms and treatment.

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Read more for support for parents on tongue-tie

Many babies have a piece of membrane under their tongue (the frenulum) which does not usually cause problems. Tongue-tie (ankyloglossia) occurs when the frenulum is abnormally short, stopping the tip of the tongue from protruding beyond the lower gum. This may cause problems with feeding as a result of the inability to move the tongue in a normal way and therefore attach and suck effectively. The frenulum may reach the tip of the tongue and be easily seen, and may be either thin and stretchy or thicker/tighter. A posterior frenulum, which is at the back of the tongue, can be less easy to see and in some cases may only be felt. If you and/or your baby are experiencing feeding difficulties, an assessment of your baby's tongue function and a feeding assessment by a specially trained professional will determine whether a division of the membrane ( frenulotomy) could help.

Many tongue-ties are asymptomatic and do not require treatment, and some may resolve spontaneously over time. In some instances, support to improve attachment is all that is needed. However, if the condition is causing problems with feeding, surgical division of the lingual frenulum can be recommended and carried out as early as possible. This may enable the mother to continue breastfeeding rather than having to switch to artificial feeding.
NICE has approved the division of tongue-tie.

FIND OUT MORE

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Information for parents and health professionals on identifying and managing tongue tie, and other useful resources on the condition.

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Why some babies need further help following a tongue tie division

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Why some babies need further help following a tongue tie division

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Is Your Baby a Tether-Berg or a Tether-Floe?

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We all know the definition of iceberg: a large mass of ice located in the water with just a visible portion protruding above the water's surface. Ice floes, by contrast, are flat floating sheets of...

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MANUAL THERAPY AND INFANT FEEDING.

What is the role of manual therapy for helping babies with feeding difficulties?

There are several healthcare professions that use manual therapy as their modality for treating the human body. Manual therapy is the hands-on method of treating the body, rather than a drug-based approach. The therapist uses a variety of techniques to support the tissues and help return function to a normal level when there has been injury or changes to the areas involved.

The techniques used can have different names depending upon the profession using them, but in general they include:

Mobilising a joint: taking it through a range of motion to promote full use, to ease ligamentous, capsule or muscular restrictions to full movement.

Soft tissue techniques: massage, stretching, inhibition, cross-fibre.

Active tissue techniques: asking the patient to work against the therapist e.g. Muscle Energy Technique.

Nerve stretching: proprioceptive neuromuscular facilitation stretching.

High Velocity/Low Amplitude Thrust: the "clicking" or "popping" noise of a joint when it is adjusted to regain motion.

Cranio-Sacral Techniques and Sacro-Occipital Technique: these are generally very subtle, "quiet" and gentle techniques. This first was developed within Osteopathy and is an extension of osteopathic principles aimed at releasing adverse tension in the tissues of the skull: meninges and other connective tissue and can be applied to other joints in the body too. The latter is the extension of Chiropractic philosophies and looks at more subtle mechanical ways of dealing with chiropractic "subluxation" patterns. Both of these approaches are popular for use in treating babies and they involve very little strong force to be applied to the body.

Most osteopaths and chiropractors who treat babies have undertaken extensive post-graduate studies in order to gain an in-depth knowledge of the embryological development of the baby. This will include the anatomy of the nerves, vessels, bones, joints and muscles relating to the brain, head, face, neck, back and body and organs during development. They understand the stages of development during embryonic life, the process of birth and the interventions or traumas that may occur during birth, and the developmental stages during the early years of life.

The aim during treatment will be, for example:

to relieve the compressions that occur whilst the baby is growing within the womb (uterus), particularly in the later months when space becomes restricted.

to relieve stresses and traumas that might result from the birth process, for example awkward presentations that require interventions such as forceps or venteuse can create trauma in the neck and head areas.

to improve the motion of the thoracic cage which houses the heart and lungs so that breathing is easier.

to improve the movement of the upper neck area so that the nerves that facilitate feeding are not impinged and the baby can physically and comfortably get their head into the right position for feeding, on both right and left side.

For the mother, osteopaths and chiropractors can work on, for instance:

the pelvis to reduce the symptoms of pelvic girdle pain (symphysis pubic dysfunction) that can make walking and daily activities very painful and awkward.

the parts of the thoracic cage (ribs and spine) that relate to the nerves that supply the breast and in turn control the milk supply and milk ejection reflexes.

the mothers muscles and joints to improve their function can help ensure that mother can achieve comfortable positions for birthing, for feeding, for sleeping.

Important Note:

In the United Kingdom there is increasing legislation to protect the general public and to ensure that health practitioners are adequately trained (to B.Sc. degree level or above), insured and continuing their professional development (ongoing training; CPD). Certain professions have their own governing body that regulates the training courses and the individual practitioners on the register, for example, Osteopaths are regulated by the General Osteopathic Council, Chiropractors by the General Chiropractic Council, whilst other professionals, e.g. Physiotherapists, are required to register with the Health and Care Professions Council that regulates many other professions too.

In law, these professional titles are protected and it is a criminal offence to use them if the practitioner is not registered with the relevant governing body.

The protected titles include the following:

However, there are several practitioners of manual therapy who do not enjoy the same legally protected status, but may well be trained to a high level or have a great deal of experience within their chosen field. It is the individual choice of the member of the public who chooses to use a non-regulated person to ensure the level training and experience is to their satisfaction and to be aware that whilst these practitioners may be a member of an association, it is not a governing body that has recourse within law to protect the public. For example, titles commonly seen include massage therapists, physical therapists, manual therapists, cranio-sacral therapists. Where nurses and midwives provide manual therapies they are still regulated by the Nursing and Midwifery Council in these roles.

For a directory of manual therapy providers with experience in treating babies with feeding issues and tongue-tie please visit www.bodywork.org.uk

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Manual Thearapy and Infant Feeding Issues

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There are several healthcare professions that use manual therapy as their modality for treating the human body. Manual therapy is the hands-on method of treating the body, rather than a drug-based approach. The therapist uses a variety of techniques to support the tissues and help return function to a normal level when there has been injury or changes to the areas involved.

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Sometimes seeing an osteopath can be helpful, especially after a tongue tie division. There is limited evidence for this, but some parents feel it is helpful. this link has a good explanation.

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Breast feeding should be the most natural thing in the world, and for many new mums it is. However, when it isn't working quite as well as it should it can be hugely distressing for both the mother and baby. Whilst no-one should feel bad if they find themselves unable to breastfeed their baby, there are plenty of reasons for giving breast feeding your best shot. Understanding why some babies struggle with breast feeding can help to identify possible solutions to the problem.

Musculoskeletal disorders are a common factor. These are muscle and joint problems usually resulting from either the birth process or the position of the baby in the uterus during pregnancy (intra-uterine constraint). These very often involve neck and jaw issues, but if a baby is distracted by musculoskeletal pain anywhere in their body, or indeed by a headache, it seems reasonable to assume that this could make feeding more challenging. Typical signs that musculoskeletal issues are a factor in breastfeeding problems include:

the baby pushing off the breast

arching the back when feeding

milk dribbling out of the mouth when at the breast

difficulty in achieving an effective latch, often due to not opening the mouth wide enough

ineffective suckling, often giving the mother sore nipples

distress or discomfort when being positioned for breast feeding.

A study published in the journal Clinical Lactation (2016) asked lactation consultants about their perceptions of musculoskeletal disorders affecting breastfeeding. The most common musculoskeletal issues were identified as congenital torticollis, sometimes known as "wry neck" (25%), and neck tension (14%). The most common latch issues were identified in this study as painful latch (24%), neck problems (18%), non-latching (9%), and tongue-tie (27%).
Looking for clues
So how would you know if your baby had a musculoskeletal problem? In addition to the feeding issues already described, babies with musculoskeletal and structural problems will often feel uncomfortable and may show this in a number of ways including excessive crying, sleep problems, and being generally unsettled. Sometimes there can also be very noticeable functional problems such as discomfort in certain positions and body positioning too.

Observations that parents might make which can indicate a musculoskeletal problem in a baby include:

Erect head control ("military" posture when held upright)

Preference to keep or turn head to one side

Inability to turn head left or right

Uncomfortable in certain positions, e.g. lying on the back or having the nappy changed

Asymmetrical posture, e.g. lying in a curved "banana" shape

Facial asymmetry: crooked smile, uneven eyes, an ear that "sticks out"

Intolerant of the car seat

Fusses or becomes frantic during tummy time

Excessive back and neck arching

Need help? Here are some ways to get breast feeding on track...
There are a number of ways that you can get help.

Lactation Counsellors - These are specially trained professionals who can offer advice and support on all aspects of feeding your baby. They can also check your baby for tongue tie if you are concerned that this may be a factor. Your Health Visitor should be able to put you in touch with your local lactation counsellors.

Support Groups - It can also be very helpful to join a local group where support is available. Your local NCT and LaLeche league will offer weekly support grounds and there are often breastfeeding support groups at your local children's centre or hospital.

Cranial Osteopathy - People are often surprised that babies may need physical therapy. There are many reasons why a parent may decide to bring their baby to an Osteopath, and these are typically linked to muscle and joint problems (i.e. "musculoskeletal"), and the effect that these may have on the child's nervous system.

Muscle, joint and cranial problems can start as a consequence of the positioning of the foetus in the womb (intra-uterine constraint), and through the birth process. Lifestyle factors such as prolonged periods in car seats and lack of tummy time, can also have an impact on the musculoskeletal wellbeing of babies and infants.

At Surrey Osteopathic Care we are often referred babies from midwifes and health visitors. Sally has attended numerous post graduate training courses on paediatric care and is very experienced when it comes to dealing with feeding difficulties. Techniques used to care for babies are always very gentle and are designed to safely and effectively help little people. These include massage and soft tissue techniques, and gentle ways to improve function of the joints (often holding techniques or gentle vibration).

Every child visiting a Osteopath is individually assessed, and any musculoskeletal or cranial issues addressed, rather than "treating" a specific problem. For a baby brought to the clinic in relation to feeding issues, a visit might typically involve: Checking the around the throat area, jaw, upper neck and back of the skull (which can often be very tender due to the strains of the birth process); checking for tongue tie; releasing the muscles of the tongue; checking muscles that often compensate for other dysfunctions that affect feeding (these are quite diverse and include the muscles at the front of the neck, the diaphragm, and the shoulder girdle); and looking for any other spinal and cranial problems which might be making the baby uncomfortable or unable to relax in the feeding position.

The techniques described above are broadly described as "manual therapy". In the study published in Clinical Lactation (2016), 91% of the lactation consultants who responded noticed breastfeeding improvement following manual treatment.
Support and the right care can make a difference!
It is recognised that early and consistent breastfeeding support can often make the difference in a mother and baby's ability to establish a functional breastfeeding relationship. So, if you are struggling, don't delay!

If you are experiencing difficulty breastfeeding your baby, seek support from a lactation counsellor, and if you think that musculoskeletal problems may be a factor, consult a skilled practitioner such as an Osteopath, who can offer hands-on care for your baby.

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Breastfeeding - Why Some Babies Struggle - Cranial Osteopathy Guildford

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Breast feeding should be the most natural thing in the world, and for many new mums it is. However, when it isn't working quite as well as it should it can be hugely distressing for both the mother and baby.

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Randomised controlled trial of cranial oateopathy for infant biomechanical issues

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Randomised controlled trial of cranial oateopathy for infant biomechanical issues

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Biomechanical issues = suckling problems, just in case you wondered!

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This can be helpful if your baby has trouble getting a mouthful of breast. Scroll down to the end of the page on the link to see the video. I’d suggest trying the koala hold too but leaning back more

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*More information on this topic can be found in my NEW BOOK on breastfeeding and tongue ties, "All Tied Up! How To Keep On Boobin' Through A Tongue Tie". Available here.
Most babies will latch on the best when they are supported to self-attach on their own, with the mother in the "laid-back" breastfeeding position, or self-attachment in the "koala" hold. Here is a video to show what this process looks like. It's an amazing thing to see (and experience yourself!)...

But what about the babies who cannot latch on well by themselves? What about the babies with tongue ties or other physical issues going on that inhibit their ability to keep enough of the areola in their mouth while breastfeeding? This is where the "flipple" technique can really help. In the following video I discuss how this little breastfeeding trick can work even better if the mother does this while her baby is in the "koala" position which looks like this:

Step 1. Try to get your knees lower than your hips as this can make it easier for some mothers.

Step 2. Put your baby's mouth right at your nipple.

Step 3. Use the "flipple" technique to get as much of your breast tissue into your baby's mouth as possible. Point your nipple very high towards their nose, try to get as much of the bottom part of your areola into your baby's mouth and use your finger to flip their top lip up after they have latched on.

*You may need to use this "flipple" technique before AND after you get a laser or scissor tongue/lip tie revision done. Some mothers find that they need to use this for quite some time as their baby get's the hang of using their new tongue!

Step 4: Watch this video to see it in action!

And here is another video demonstrating the flipple in an upright position but baby is supported from behind by both a pillow and their mother's arm...

Have you used the flipple and/or the koala hold? Share your experiences below! If you need some help getting your baby to latch on or have questions about tongue ties please CLICK HERE.

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How to get a better latch! The exaggerated latch or "flipple" breastfeeding technique... - The Milk Meg

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And here is another video demonstrating the flipple in an upright position but baby is supported from behind by both a pillow and their mother's arm... Have you used the flipple and/or the koala hold? Share your experiences below! If you need some help getting your baby to latch on or have questions [...]

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This one has precise instructions

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Wide Pain-Free Latch for Beastfeeding Using Thumbs-Up or Flipple Technique

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Improve your latch with this easy checklist - in cradle and football hold. (Checklist not viewable on your phone.)

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Information handout which I wrote for patents on what to expect when they take their baby for a tongue tie assessment. It covers how to manage feeding during the days after a tongue tie division. You are welcome to use it

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Book on tongue tie written by a parent for parents

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Book on tongue tie written by a parent for parents

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This is a link to the amazon page for this ebook. It is very much what it says - a parents' guide written by a parent for parents

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tongue tie: breastfeeding and beyond. a parents' guide to diagnosis

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Tongue tie: breastfeeding and beyond. A parents' guide to diagnosis, division and aftercare.

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Discovering your baby has a tongue tie can be a very stressful, emotional, and painful experience, especially if they are struggling to breastfeed. Whilst there is information available on the internet, searching for it is very time consuming. Tongue Tie: Breastfeeding and Beyond brings it ...

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Although tongue tie division is provided by the local nhs, sometimes parents chose to go to a private tongue tie divider. The Association of Tongue Tie Practitioners maintains a list of members who offer private tongue tie assessment and division.

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Whether you are a parent or a health care provider, we hope you will find our website helpful in accessing all of the information you need about tongue-tie and the support available.

The Association of Tongue-tie Practitioners (ATP) was set up in 2012 by a group of tongue-tie practitioners from the NHS and independent sectors with the aims of:

Increasing awareness about the effects of tongue-tie on babies especially with regard to both breast and bottle feeding.

Supporting parents of tongue-tied babies to access safe and effective care.

Assisting tongue-tie practitioners to provide safe and effective care through training and sharing knowledge and experience.

Providing resources and education for healthcare providers who refer babies for tongue-tie division.

The Association of Tongue-tie Practitioners (ATP) is also actively working to redress inaccuracies in the reporting and documenting of the effects of tongue-tie on babies especially with regard to both breast and bottle feeding.

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Association of Tongue-tie Practitioners | For parents & health care providers, all of the information you need about tongue-tie and the support available.

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Whether you are a parent or a health care provider, we hope you will find our website helpful in accessing all of the information you need about tongue-tie and the support available.

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A useful guide for parents with pictures and descriptions by a very knowledgeable American Lactation Consultant

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Many parents are concerned that their baby may be tongue-tied. Many breastfeeding problems are blamed on tongue-tie. Almost everyone has a lingual frenulum, or bit of tissue under the tongue that helps connect the tongue to the floor of the mouth. The most important thing is that the tongue can move properly.

Most breastfeeding problems are caused by misunderstanding what babies need. Help with positioning and latch is the first step to improving breastfeeding. LLL meetings, LC consultations, breastfeeding or baby cafs are all good resources for getting individualized help.

Some tongue-tied babies can make breastfeeding work. Even if your baby has an obvious tongue-tie, first get help from a lactation professional.

Most professionals agree that a tight frenulum that attaches to the tip of the tongue can make it more difficult for babies to feed. These tongue-ties can be easy to treat in a doctor or dentists office. Figure 3 shows a very tight frenulum that experts agree needs treatment.

There is more controversy about babies who do not have good tongue mobility but do not have a tight frenulum at the front of the tongue. New anatomy research suggests that tight fascia (the soft tissue that joins body structures) may be responsible. Depending on the cause of the tightness, therapy may be the best option. Physical therapy is best studied for neck muscle imbalances caused by the babys position during pregnancy, other body work may be helpful as well.

Heres how you can look at your own babys tongue movements:

The first thing to assess is whether your baby can stick out his or her tongue. If you touch your baby's lips, he will probably open his mouth. You can then touch the front of his lower gum with your fingertip. This makes him stick the tongue out. We want to see the tongue come out flat over the lip without denting or dimpling.

Next, we want to see if your baby can lift her tongue way up to the roof of the mouth. All the way up is perfect, half way is enough for most babies to be able to breastfeed. Again, her mouth should be open when you check if the tongue can lift up.

Tongue-ties:

This baby (figure 3) has an obvious tongue-tie. You can see the membrane right at the front of the tongue, and you can see how it makes it hard for him to lift his tongue up.

figure 3: obvious tongue-tie

Babies with a tight frenulum may have a notch in the tip of the tongue when they try to move the tongue (figure 4). This is also called a "heart-shaped" tongue. Some babies have a notch but can still lift the tongue normally. Remember we want to look at the whole baby and not just one feature.

Babies with a tongue-tie will often raise the sides of the tongue while the front of the tongue pulls downward toward the floor of the mouth. Professionals call this a "low tongue posture". See (figure 5)

figure 5: low tongue posture

Babies with restricted or weak tongue movements will have a high, narrow roof of the mouth (figure 6). This is an important "double check" or confirmation that the tongue is not moving well. There are other reasons to have a high or narrow palate too, such as being in a position during development that prevented the baby's head from expanding side to side.

Having a shorter lower jaw than average can affect tongue strength. This baby (figure 7) does NOT have a tongue-tie. Dividing the frenulum when the real reason for sucking problems is a short jaw or muscle tightness in the face or neck will not help and can often make the problem worse.

Again, if your baby does seem to be tongue-tied, please get lactation help first. Some tongue-tied babies are able to breastfeed without treatment with some special help latching on. An IBCLC should also be able to help determine whether a breastfeeding problem is from a tongue tie or is from poor latch or positioning, a short jaw or tight muscles and communicate these findings with your baby's primary health care provider.

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Many parents are concerned that their baby may be tongue-tied. Many breastfeeding problems are blamed on tongue-tie. Almost everyone has a lingual frenulum, or bit of tissue under the tongue that helps connect the tongue to the floor of the mouth. The most important thing is that the tongue can move properly.

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It’s only a slight tongue tie - it won’t interfere with feeding. . . 

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It’s only a slight tongue tie - it won’t interfere with feeding. . . 

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"Baby has a "mild" tongue tie but it's too small to cause any feeding problems."

"Baby has a "slight" tongue tie but it doesn't need treating".
"Baby has a small tie that can't be treated"

I meet so many parents who have been told this, it seems to be popular at the moment. Parents I meet because of feeding problems; problems that are of course not being caused by that "mild tongue tie". Except they are...

Babies who might have reflux, colic or wind because they are either unable to make or maintain a deep enough latch at the breast/bottle, spending their entire feed sucking in air.

The resulting symptoms can be wide and varied, complicating diagnosis further. Some feed constantly, other sporadically; some reflux, vomit, spluttering or gulp, bobbing on and off when the milk ejection reflex (let down) is triggered or the bottle is tipped. Some gain weight whilst others don't and if baby can't organise co-ordinate their sucking and breathing fast enough, this is often misdiagnosed as "fast let down", or that baby needs a slower teat.

Some are told as their baby can protrude their tongue, it isn't restricted enough to cause problems; without considering that "pulling tongues" is really quite different to opening your mouth wide and brining your tongue forward to feed; or that you also need lift and sideways function as well as extension. Others are told the tie isn't impacting after barely a cursory look in baby's mouth, or a quick sweep under the tongue.

The other BIG problem with simply having a quick peek in a baby's mouth, is you can often confirm whether a frenulum is restrictive, but it's much harder to confirm insignificance the same way. In order to do so you have to piece together the signs and symptoms, watch the baby at the breast/bottle, assess their suck and what the tongue is actually doing during the feed. If there are significant indicators, a specialist who is competent lifting the tongue is needed to complete the picture.

Because problems caused by tongue tie, aren't caused by how the tie looks, but about how it allows the tongue to function (or not), and looks can be deceptive. A tie can be like a super thin wire, or slightly wider and diaphanous but still visually "tiny"; yet if it is tightly holding the tongue it doesn't matter if it's super thin or a more chunky number. Furthermore a tie can look insignificant from the front, but when assessed properly, one can find the frenulum runs back down the tongue, getting thicker and causing significant restriction further back.

"It is not always possible to predict which tongue ties will inhibit breastfeeding, as characteristics of the mother's breasts also have an effect on such factors as milk transfer. The length of the frenum (or the apparent severity of the tongue tie) has no bearing on whether the baby will be able to breastfeed efficiently.

Mr Mervyn Griffiths found that: "...the thickness, shape and percentage length of the tongue tie were not predictors of success or failure. ...This suggested that the function of the tongue (i.e. the symptoms themselves) produced by a combination of tongue, mouth and tongue tie is more important than simply the appearance of the tie." (tonguetie.net)

Anther myth is people generally consider ties right on the tip of the tongue to be the "most severe", those nearer the back "insignificant".

Whilst cosmetically this may be the case, a tie anywhere down the tongue can significantly impede function, without causing any dramatic visual changes or pulling to a heart shape.

Regardless of where the tie is, a baby will still compensate with an alternative tongue action, which may (or may not) lead to problems. They may still fail to make a seal at the breast or bottle, pulling, slipping or gradually working their way back to a shallow latch.

Lastly one could also argue the "smaller" the tie, the more restrictive it is. Long, stretchy frenulums may not be restrictive whereas short, tight, small ties are likely to result in less movement. Does that sounds less significant to you?

Updated 23.3.17

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"Baby has a "mild" tongue tie but it's too small to cause any feeding problems." "Baby has a "slight" tongue tie but it doesn't need treating". "Baby has a small tie that can't be treated" I meet so many parents who have been told this, it seems to be popular at the moment.

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This review shows how things have moved on in six years compared to the 2005 review with more tongue ties being snipped and a greater understanding developing.

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Details and Download Full Text PDF: Tongue-tie and breastfeeding: a review of the literature.

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PubFacts seeks to make the world's scientific research easy to locate, access, and collaborate on.

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which gives some background and general information

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This review written in 2005 gives an idea of where thinking on TT had reached by that date

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Common problem or old wives' tale?

The resurgence of interest in breast feeding has been accompanied by a lively debate about the significance of "tongue tie" or ankyloglossia. Symptoms attributed to tongue tie include nipple pain and trauma, difficulty in the baby attaching to the breast, frequent feeding, and uncoordinated sucking. These problems may result in the mother deciding to terminate breast feeding prematurely, slow weight gain for the baby, and even hypernatraemic dehydration. Speech defects have also been attributed to tongue tie. Strong views have been expressed by many eminent authors on the subject (box 1).

This paper reviews what is known about tongue movements and the significance and treatment of tongue tie. It is based on two literature reviews, one conducted on behalf of NICE by one of us (MR) and updated by further searches of published and grey literature and conference abstracts. The publications reviewed for this paper are summarised in table 1.

As our review found little high quality objective evidence, we begin by making explicit the personal experience and bias with which we commenced the review. One of the authors (MR) felt that tongue tie is an important issue-she experienced pain for many weeks while breast feeding her first child, who exhibited features said to be typical of tongue tie, and has since discussed this issue widely with lactation specialists and women having similar problems. The other (DH) accepted that ankyloglossia occurs in dysmorphic infants and occasionally in otherwise normal babies, but was sceptical about the high prevalence of the condition now being described by several authors.

ANATOMY AND PHYSIOLOGY

The tongue is a highly mobile organ made up of longitudinal, horizontal, vertical, and transverse intrinsic muscle bundles. The extrinsic muscles are the fan-like genioglossus which is inserted into the medial part of the tongue and the styloglossus and hyoglossus into the lateral portions. The sub-lingual frenulum is a fold of mucosa connecting the midline of the inferior surface of the tongue to the floor of the mouth. Tongue tie is the name given to the condition arising when the frenulum is unusually thick, tight, or short. There are many variations and differing degrees of severity (fig 1).

The movements of the tongue during infant feeding have been studied by cine-radiography and more recently by ultrasound. Ultrasound reveals some similarities between the movements made by the baby when either breast or bottle feeding, but also some important differences. The tongue is projected further forward in breast feeding and the human nipple elongates during each suck in a way that an artificial teat cannot do. During feeding, the artificial teat, or the nipple together with some breast tissue, is held fully in the mouth with the tongue covering the lower gum ridge. The nipple is protected from damage and pain at the back of the baby's mouth. The baby's lower jaw is then elevated, compressing the artificial teat, or the breast immediately behind the nipple, while the front of the tongue moves up to aid the expression of milk. In breast feeding, this is by compression of the milk ducts under the areola. A wave of upward movement of the medial part of the tongue progresses backwards, and the expression of the milk is further facilitated by negative pressure generated by downward movement of the back of the tongue and the lower jaw and, in breast feeding, by the active expulsion of milk once the let down occurs.

In coordinated feeding, the sucking, swallowing and breathing movements follow in a 1:1:1 sequence. This can take several days to become established in healthy full term infants. In pre-term infants and in some term infants a variety of poorly coordinated feeding movement patterns are observed and sometimes persist. Antenatal ultrasound studies show that mouth and tongue movements are already well developed in association with intra-uterine yawning and crying.

HYPOTHESES

Review of the literature and expert opinion gave rise to the following hypotheses:

Tongue tie is a definable condition

Tongue tie affects 3-4% of infants

The tight frenulum prevents the infant from getting the tongue over the lower lip and gum ridge and therefore can cause feeding problems, particularly affecting breast feeding, leading to pain for the mother and poor infant weight gain; it can also affect bottle feeding

The impact of a tight frenulum varies between mother-baby dyads

A tight frenulum can also cause problems in older children and adults, involving speech, dental hygiene, licking ice cream, and French kissing

Division of the frenulum (frenulotomy) is a low risk effective treatment

The condition is genetic

CASE DEFINITION

Can tongue tie be defined-and to what extent do individual observers agree on the diagnosis? The length of attachment of the frenulum varies widely. In some babies it extends to the tip of the tongue. There may be an indentation of the anterior edge, referred to as a heart shaped tongue. The appearance of the tongue is not sufficient on its own to make a diagnosis, as the thickness and elasticity of the frenulum also vary widely and affect the extent to which normal tongue movements are inhibited (see fig 1).

In four published studies of tongue tie in babies, the initial selection of possible cases from the whole newborn population was based only on appearance and was done by one individual (Ballard and colleagues), or by one individual with confirmation of positive diagnoses by one other observer (Messner and colleagues), or accomplished by providing staff with a selection of photos (Hogan and colleagues, Ricke and colleagues). We have not found any formal data on observer agreement or variation in this process. The method of selection in the study by Masaiti and Kaempf is unclear but cases were probably selected on the basis of breast feeding problems. Two authors (Messner, Ricke) aimed to reduce bias by trying to avoid specific mention of tongue tie to mothers but acknowledge that this was difficult.

All authors agreed that function is more important than appearance and Hazelbaker designed an Assessment Tool for Lingual Frenulum Function (ATLFF). Ballard used this tool but did not examine inter-rater reliability. Ricke et al found that the inter-rater agreement using the ATLFF was only moderate and that many infants did not fit in any of the categories defined by Hazelbaker.

BIRTH PREVALENCE OF TONGUE TIE

There is agreement among authors that tongue tie is found in around 3-4% of babies, with the exception of Hogan et al who report 10.7%. All report a male preponderance with ratios varying from 1.5:1 to 2.6:1.

THE IMPACT OF TONGUE TIE

Maternal pain during feeding, sometimes accompanied by trauma, and difficulty in the baby taking the breast, are the main breast feeding problems attributed to tongue tie. Attributing pain during breast feeding to tongue tie is not straightforward, however, since pain is a common problem that can result from several other causes, including attachment problems unconnected with tongue tie, and infection. Ricke and colleaguesreported that more tongue tied infants than controls were bottle fed at one week but there was no significant difference at one month, though attrition meant that numbers were small. Messner et al found no difference in the rate of breast feeding between tongue tied infants and controls at 2 months but a significant difference in the numbers of mothers reporting problems with breast feeding.

Ramsay measured the distance from nipple tip to the junction of the hard and soft palate by sub-mental ultrasound. The distance decreased from 7.99 mm (±2.80) to 6.49 mm (±1.87) seven days after frenulotomy. This change, though statistically significant, is small and its practical significance is unknown. The tongue movements were said to become "more normal".

VARIATION BETWEEN DYADS

Hogan and colleagues found that more than half of babies with tongue tie had no problems breast feeding but could not show any correlation between severity of tongue tie and feeding difficulty. This is perhaps surprising, but it may be that only a small shift in positioning on the breast is sufficient to eliminate pain and improve feeding. Ricke and colleagues reported that 80% of tongue tied infants were breast feeding successfully at one week. It is of interest that in two case series of older children presenting with speech difficulties and other problems attributed by the authors to tongue tie, 21/25 mothers (Messner and Lalakea) and 80% of an unspecified number (Fernando) who were asked about breast feeding reported no significant difficulties.

OTHER PROBLEMS

Several case series report a range of other problems in older children associated with ankyloglossia-speech defects, difficulty in licking the lips or in kissing, dribbling, etc. These are difficult to evaluate as the authors do not give details of the catchment population, referral patterns, or detailed criteria for inclusion in the series.

INTERVENTION

All authors agree that frenulotomy in the newborn is a low risk minor procedure, performed without anaesthetic. The presence of the deep lingual vein just lateral to the midline means that significant venous bleeding could occur if technique is not meticulous but we found no reports of serious adverse events. In older children the procedure needs an anaesthetic and sometimes a frenuloplasty, which carries some risk of scarring.

Ballard and colleagues reported a marked fall in maternal pain scores after the procedure. Hogan and colleagues randomised their cases to immediate or delayed intervention and found that frenulotomy was much more effective than advice from a lactation counsellor. They reported dramatic and rapid, often immediate, improvement after the procedure in most of their cases; improvement was noted in 95% of babies. The measurement of outcomes was not blinded. The precise criteria for improvement were not specified. Improvement was not always immediate, but this could be due to the need for sore nipples to heal or for the baby to re-learn optimal patterns of suckling.

In case series of older children and adults, some striking improvements were noted after surgery, but many of the children showed only gradual or modest improvement, particularly where the articulation of speech was concerned; these children often needed continuing speech therapy and this was attributed to the need to un-learn established patterns of articulation. The absence of any comparison or control cases makes these reports impossible to evaluate and we found no comparative studies or randomised trials addressing the role of tongue tie or frenulotomy in older children.

IS ANKYLOGLOSSIA INHERITED?

To define the inheritance of a condition, a robust case definition is needed, but tongue tie varies markedly in severity and is not an all-or-none condition. When an anomaly is identified in a newborn infant, the family searches its collective memory for other similar cases but, in the case of tongue tie, it would be impossible to assess the validity of that diagnosis in retrospect. None of the studies we reviewed considered these issues and none had gathered systematic family data across a number of families with and without the condition. Notwithstanding the comments made in several papers, no conclusions can currently be drawn about family history.

AN OVERVIEW

Tongue tie is at first glance a minor issue, but from the results of the only randomised controlled trial yet conducted, Hogan and colleagues suggest that at least 3% of newborns (57/1866) would benefit from frenulotomy and that this would increase the rate of continuing breast feeding. Most of the literature on tongue tie has been in connection with breast feeding; however, Hogan et al report that of the 57 babies in their study who benefited from frenulotomy, 40 were breast fed but 17 were artificially fed. If they are correct, this is a very common congenital anomaly that affects both breast fed and bottle fed babies, and up to 18 000 such procedures should be performed each year in the UK. It is therefore important to ask whether the evidence supports that rate of intervention and to scrutinise the evidence with a particularly critical eye.

There were a number of methodological problems with most of the studies we reviewed. These included:

Inadequate assessment of inter-observer reliability of the initial diagnosis, the dynamic assessment of feeding and the maternal symptoms

Ethical and practical difficulties in concealing the suspected diagnosis from the mother, thus potentially introducing a bias by raising the expectation of breast feeding problems and of improvement from intervention-this is, however, a common limitation in most studies of breast feeding problems

Poorly defined outcome measures; it is particularly difficult to establish an objective assessment of improvement, when the primary outcome measure is reduction in maternal pain during breast feeding

The dilemma of when to assess and intervene for tongue tie; if done very early, before breast feeding is established, as in the Ballard et al study, improvements may be wrongly attributed to the procedure (because suckling efficiency improves over the first few days and weeks), but if done later (as in Hogan et al), many mothers may already have sore nipples or have given up breast feeding.

CONCLUSIONS

We began this review by stating our personal bias. While DH confesses to still being somewhat more sceptical than MR, we are in complete agreement on the following conclusions:

Individual case histories suggest that some babies do have a tight frenulum (tongue tie) which can inhibit breast feeding and, in some cases, bottle feeding as well

Although frenulotomy is a simple low risk procedure, it should be carried out only by those who have been trained in the procedure

It can be justified only if it is likely to lead to significant improvement in the comfort and the continuation of breast feeding, or of other longer term problems for the child

We do not know the true prevalence of significant tongue tie

There is no evidence one way or the other about inheritance

On current evidence, there is no justification for actively searching for tongue tie during routine examination, but when mothers are having difficulty in breast feeding this should be considered as one of several possible causes

The diagnosis should rest primarily on observation and analysis of feeding difficulties rather than the static appearance of the tongue

It may be wise to be particularly cautious in making this diagnosis in the first two or three days before lactation is established

The problem is of sufficient interest and importance to merit further studies of both breast and bottle fed babies, in which more precise case definition, measures of inter-observer reliability of pre- and post-intervention assessment, and ultrasound imaging are likely to play a key role

Given the evidence that breast feeding has many advantages for both mother and baby, funding should be sought for carefully planned definitive studies on the issue.

Common problem or old wives' tale?

View Abstract

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Common problem or old wives' tale? The resurgence of interest in breast feeding has been accompanied by a lively debate about the significance of "tongue tie" or ankyloglossia. Symptoms attributed to tongue tie include nipple pain and trauma, difficulty in the baby attaching to the breast, frequent feeding, and uncoordinated sucking.