What is a tongue-tie?
In some babies, the tongue is restricted by a thin membrane underneath it. This can make the tongue look forked, shortened, or heart-shaped when the tip is lifted.

Recent studies have shown that some tongue-tied babies don’t feed well, and will benefit from having the tie snipped by someone suitably trained. The Department of Health has recently issued guidelines on treating tongue-tie in breastfed babies

How can it affect feeding?
Babies need free tongue movement to feed and swallow comfortably. When breastfeeding, they need to press the tongue-tip into the breast, with the nipple far back in the mouth, against the soft palate. If the tongue movement is restricted, they may not attach to the breast fully, or at all. Incomplete attachment to the breast results in lower fat content of the milk, as some parts of the breast are not fully drained.

When bottle feeding, babies need to keep the teat in the mouth and push easily against it.

Possible problems in baby:
• difficulty attaching to the breast and/or staying attached
• very frequent and/or long feeds
• difficulty in swallowing and greater intake of air
• colicky symptoms from increased intake of milk sugar (because fat content is lower, more volume of milk is needed to give the same calories, and this means more lactose in the gut, causing indigestion)
• dribbling at the bottle
• poor weight gain even with copious intake
Later on:
• difficulty in chewing and swallowing lumpy food

Possible problems in mother:
• sore, damaged nipples
• over-supply to compensate for reduction in milk fat (see above)
• reduction in supply over time from the difficulties encountered
• mastitis from poor drainage and nipple trauma
• exhaustion from frequent, long feeds

Other factors which may aggravate the condition or give similar symptoms:
• long labour, and/or difficult birth (eg ventouse, forceps, breech presentation, caesarean birth) causing tension or compression in the head, which may affect tongue movement and make it harder for baby to open the mouth
• swollen breasts from fluid in tissue behind nipple (eg from high blood pressure) or from milk engorgement around 3-4 days
• very large, long or inverted nipples

How can tongue-tie be treated?
We recommend that you do all you can to improve feeding while feeding is under review, or while awaiting referral for treatment. Skilled support in getting your baby into a closer position to attach to the breast more easily will improve symptoms, and may mean that no treatment is needed. An experienced midwife or health visitor, or a breastfeeding counsellor, lactation consultant or other breastfeeding specialist can help with this. Trying different teats for a bottle-fed baby may help. Cranial osteopathy may relieve compression of the head or discomfort from a difficult birth. As time goes on, it may become easier for the baby to compensate for a shortened tongue, and the tie may break later.

Getting good help before treatment also means that any snipping of the tongue-tie will show whether it was actually a factor in the feeding problem.

If there is little improvement from the above measures, the tie can be snipped. This does not damage the tongue at all, takes only a few seconds, and causes little if any pain or bleeding. No anaesthetic is needed, and the baby can feed immediately afterwards. Often the feeding problems improve or resolve. If not, your baby will need to be reviewed for other possible causes of feeding problems.

Where can I get the tongue-tie snipped?
In some areas, treatment is easily available. Ask your maternity unit if there is an Infant Feeding Adviser to arrange treatment. You could ask your GP to refer you to the paediatricians or oral surgeons, but if there are feeding problems, you will need to ask for an urgent referral. You may need to work hard to get support.What can happen if the tie is not treated?
Some mothers are unable to continue direct breastfeeding if there are severe difficulties, but expressed milk could be given if baby can manage the bottle well. In some babies, the tie loosens or breaks on its own, so there is no way of predicting whether a tongue-tie will affect chewing or speech later.

What happens after treatment?
Most babies show improvement in feeding, but this may take some time, particularly if other factors are involved in the problems (see above). It is good to give feedback to all the health professionals involved in monitoring the baby’s progress, so we learn how tongue-tie can affect feeding, and how simple and effective treatment can be.