Tongue-tie: signs, effects on feeding and treatment

Under the tongue is a strip of tissue called the frenulum, which attaches the tongue to the floor of the mouth. In tongue-tie it is shorter or tighter than usual. NHS Start for Life says tongue-tie can range from mild to severe, and in severe cases the tongue may be completely fused to the floor of the mouth.

The NHS says tongue-tie may not cause any problems, but it can make it difficult to move the tongue. For example, you may not be able to move your tongue from side to side, lift it up or stick it out.

You may be able to see tongue-tie by looking into a newborn's mouth when they yawn or cry, though NHS Start for Life says it is not always easy to spot. The NHS says the skin connecting the tongue to the bottom of the mouth usually looks shorter or tighter than usual, and the tongue may look heart-shaped when lifted or stuck out.

In babies, tongue-tie can make it difficult to breastfeed or bottle-feed. Some babies with tongue-tie have no problems at all and may still be able to latch on and feed well.

• Difficulty attaching (latching) or staying attached to the breast or bottle teat.

• Feeding for a long time, with a short break, then feeding again, and needing to be fed very often.

• Dribbling a lot during feeds.

• Coughing, choking or making clicking noises when feeding.

• Taking only a small amount of milk at each feed.

• Seeming unsettled and hungry all the time.

• Losing weight or struggling to put on weight.

NHS Start for Life says tongue-tie can make it harder for a baby to latch on properly, which can lead to sore or cracked nipples, a low milk supply because the baby is not feeding well, and engorged breasts that can lead to mastitis. The NHS adds that if you are breastfeeding you may have sore nipples or painful and swollen breasts.

A clicking sound as a baby feeds can also be a sign that you need support with positioning and attachment at the breast, so it does not always mean tongue-tie. NICE Clinical Knowledge Summaries advise assessing positioning and attachment and arranging a paediatric referral if there are concerns about dehydration, faltering growth, infant development or an anatomical abnormality such as tongue-tie that may be affecting attachment and feeding.

The NHS says treatment is not usually needed if tongue-tie is not causing any problems. If it is causing problems, such as difficulty feeding in babies, treatment may include breastfeeding or bottle-feeding advice from a trained health professional, and a small operation to cut the piece of skin connecting the tongue to the bottom of the mouth.

The procedure is called a frenulotomy. NHS Start for Life says it is carried out by specially trained doctors, nurses or midwives and is very quick, taking a few seconds. It simply involves snipping the short, tight piece of skin, and generally no anaesthetic is used. As soon as it is done you can feed your baby, which helps heal any bleeding. The NHS says that after surgery most babies get better quickly and are able to feed better.

In older babies, children and adults the NHS says the surgery is usually done under general anaesthetic.

NHS Start for Life says that if your baby has tongue-tie it will hopefully be picked up at the first routine check by your midwife. It is not always easy to spot and may be discovered later, usually after feeding issues become apparent.

Speak to a midwife, health visitor or GP if you think your baby or child has tongue-tie or is having difficulty breastfeeding or bottle-feeding. A GP may be able to help if you are an adult and think you have tongue-tie. NHS Start for Life notes that the Association of Tongue-tie Practitioners has a directory of NHS tongue-tie practitioners.

The NHS says tongue-tie is most common in babies, but it can affect older children and adults, who may find the tongue hard to lift, stick out or move from side to side. A GP may be able to help an adult who thinks they have it. If treatment is needed, surgery is usually done under general anaesthetic.

The NHS pages used for this guide do not describe effects on speech, so ask a GP or a speech and language therapist if you are concerned about a child's speech.

Speak to a midwife, health visitor or GP if your baby is struggling to feed or you are worried about weight gain. NHS Start for Life lists the National Breastfeeding Helpline for confidential breastfeeding information and support, which runs 24 hours a day, every day of the year, and points to the NCT website for more on tongue-tie.

On the NHS, referral usually runs through the midwife, health visitor or GP to a local tongue-tie service, and waiting times vary by area. Some families see a private practitioner to be seen sooner. If you do, it is reasonable to ask about the practitioner's training, whether a feeding assessment is part of the visit and what follow-up support is offered. NICE has published interventional procedures guidance on dividing tongue-tie for breastfeeding (IPG149), now filed under its HealthTech guidance, so you can ask how current guidance applies.