Tongue tie

Read our guide below which explains about tongue tie, how it affects feeding and how the procedure involved.

You can also download a PDF version of this patient information by following the link on the right.

What is a tongue tie?

Also called Ankyloglossia, it’s a common condition where the membrane that attaches the tongue to the floor of the mouth (the frenulum) is shorter or tighter than usual.

Around 1 in 10 babies are born with a tongue tie with approximately half of those babies experiencing a feeding difficulty. More boys than girls are affected and there is often a family link. If there’s restriction of tongue movement, this can sometimes cause problems with breast or bottle feeding.

Does a tongue tie affect feeding?

Yes. Babies have problems achieving or maintaining a good latch on the breast, or may not manage a good suckling technique. This can lead to a mother experiencing:

• sore nipples
• misshapen nipples
• poor milk drainage, leading to possible blocked ducts, mastitis, and reduced milk supply.

Your baby may:

• be unsettled on the breast
• be sleepy
• slip off excessively
• be unsatisfied after feeds
• want frequent or prolonged feeds.

They may also:

• dribble or splutter
• make clicking noises
• have poor weight gain
• have excessive wind or reflux.

Bottle fed babies tend to dribble a lot or take a bottle very slowly or too fast causing coughing and spluttering.

If you’re experiencing these problems talk to your midwife or health visitor. They may refer you to the Infant Feeding Clinic.

Would dividing the tongue tie be beneficial?

If your baby’s frenulum is elastic enough, it may not cause a problem with feeding. You may just need help and support from the Infant Feeding Team.

Many babies grow up with no further problems. But if there are continuing feeding issues, with poor tongue function, we will disciss the benefits and risks of tongue tie division (frenulotomy) with you. We can refer you and your baby to have the simple procedure to release the tongue tie.

Possible complications of tongue tie division

These are rare. There are very few nerve endings in that area of a baby’s mouth, so there’s little pain.

Possible complications include:

• a tiny amount of bleeding that stops within a couple of minutes
• excessive bleeding (risk is is 1 in 300)
• infection (risk is 1 in 10,000)
• damage to the tongue or mouth area (extremely rare)
• occasional grow back or reattachment of the tongue tie.

Some babies can be very unsettled for a few hours or days after the procedure and these babies may find latching and suckling more difficult for a while before you see any improvement.

Feeding may be variable for a few weeks while the tongue muscles strengthen.

Tongue tie division referral and procedure

Not all midwives/doctors are trained to identify tongue ties but can help identify feeding challenges. They can refer you to the specialist Infant Feeding Team as needed.

Following discussion and appropriate feeding support by the staff in the Infant Feeding Clinic, we may give you an appointment for your baby’s procedure. This will usually be within 1 to 2 weeks but can sometimes take longer. Private practitioners are also available. See the websites listed at the bottom of this page.

Pre-procedure Vitamin K dose

Our guideline also states that babies having a tongue tie division must have had Vitamin K once via an injection, or at least 2 oral doses more than 24 hours before the procedure. This is to help with blood clotting. If your baby has not had this treatment for any reason then it can be arranged with your GP.

Where the procedure will happen and who will do it

At Stoke Mandeville Hospital by a health professional with specific training as a tongue tie practitioner. They’re skilled and experienced in dividing tongue ties in babies under 6 months old.

On the day of your appointment

You’ll meet the tongue tie practitioner in the Children’s Outpatient department at Stoke Mandeville Hospital. They’ll discuss any feeding issues
and relevant medical history. They’ll also re-assess and discuss your baby’s tongue tie, explain the procedure and ask you to sign a form giving your consent to the procedure.

Occasionally, our practitioners may feel that your baby needs a referral to an ENT specialist (ear, nose and throat). If this is the case, the procedure won’t take place on this day and we may offer you a referral to the John Radcliffe Hospital in Oxford.

If possible, bring your baby to the appointment ready for a feed, as well as:

• a blanket to wrap your baby in after the procedure
• your red book for recording the procedure
• a car seat to carry your baby inside the hospital
• a feed if you’re bottle feeding.

What the procedure involves

The consultation and procedure should take approximately 35 minutes. Parents can accompany their baby to the treatment room, where we’ll wrap your baby in a hospital towel with the shoulders supported by you. Using sterile gloves, the tongue tie practitioner will gently lift the tongue with two fingers. Using sterile, blunt ended scissors, the tongue tie practitioner will snip the frenulum with the other hand.

The procedure takes only a few seconds. Your baby will immediately be picked up and cuddled. We may apply pressure under the tongue with gauze to stem any bleeding and hand your baby to you.

Following a tongue tie division

Any crying and bleeding usually stops quickly and you will be encouraged to cuddle and feed your baby straight away to soothe them. Help with latching onto the breast will be offered as needed. You may experience an instant improvement with your baby's feeding but sometimes it takes a few days or weeks to notice an improvement. Occasionally there is no improvement.

It’s a good idea to feed your baby as responsively as they need over the following days. This helps to strengthen the tongue muscle for more effective feeding, encourages healing and reduces the risk of the frenulum re-attaching.

Approximately 4 in 100 babies have feeding issues after division. This may happen when the wound heals in a way that the frenulum re-attaches. Sometimes a
frenulum can reform.

If your baby needs extra support

If you notice a deterioration in feeding 3 to 4 weeks after division, contact the Infant Feeding Clinic or your health visitor. You can access support from the Infant Feeding Clinic until your baby is 28 days old. Alternatively your health visitor can offer breastfeeding support as needed.

It’s common for babies to be unsettled and frustrated on the breast at times whilst learning to use their ‘new’ tongue. This is because the tongue muscles are likely to feel tired and achy while the muscles strengthen.

Extra cuddles, skin to skin and feeding little and often as your baby needs may help. To improve your baby’s tongue function, there are some simple
tongue exercises (see below).

Wound healing

A white/yellow diamond shape area normally develops under the tongue after a couple of days which is a normal part of the healing process. This doesn’t appear to be painful and the size of the wound will reduce and then disappear over the next 7 to 14 days.

You can give paracetamol liquid (brands include Calpol®) to babies over 8 weeks old as per package instructions to reduce pain. Babies younger than this shouldn’t
need such pain relief. However, if you’re concerned that your baby’s in pain contact your GP/Infant Feeding Team for a review. We don’t routinely offer a follow-up appointment after a tongue tie procedure.

If you’re concerned

Contact your Health Visitor or GP or call the Infant Feeding Team on 07798520830 (Monday to Friday 9am to 4pm). In an emergency contact your local Accident and Emergency Department.

If your baby bleeds following tongue tie division

It’s un-common but there have been reported cases of bleeding after tongue-tie division, usually on the same day or within the next few days, after the babies
have returned home.

If this happens, the bleeding is usually very light. It may be triggered by strenuous crying (resulting in the tongue lifting and stretching the wound). Or when the wound is disturbed during feeding, particularly if the wound is caught by a bottle teat, dummy/pacifier or tip of a nipple shield.

If you notice any blood in your baby’s mouth then offer the baby the breast or bottle and feed them. This will usually stop the bleeding within a few minutes just as it did immediately after the procedure. If the baby refuses to feed then sucking on a dummy/pacifier or your clean finger will have a similar effect.

If the bleeding is very heavy or doesn’t reduce with feeding, and doesn’t stop within 10 minutes of feeding/sucking, apply pressure to the wound under the tongue with two fingers using a clean piece of gauze or muslin for 5 minutes. Your practitioner will have given you some gauze during the procedure suitable for this.

Don’t apply pressure under the baby’s chin as this can affect breathing.

If bleeding continues, apply pressure to the wound and take your baby to hospital. Call an ambulance if you live more than a very short distance from the
Accident and Emergency Department, or have no-one to drive you. Take your baby’s Child Health Record (Red Book) with you.

Infection

The risk of infection is very rare. Sterilise any bottles, dummies or nipple shields carefully before use. If infection occurs your baby will be generally unwell/very unsettled/lethargic with a fever. Pus under the tongue may or may not be present.

If your baby has any of these symptoms or you are concerned, please see your GP urgently or contact 111.

Tongue exercises

When a baby has a tongue tie, the range of tongue movement is the most important factor in the ability to breastfeed successfully. If tongue movement is restricted due to/after division of a short or tight frenulum, tongue exercises may help to improve tongue mobility and facilitate an efficient suckling technique.

Breastfeeding is a good exercise as your baby will instinctively move their tongues which will help strengthen the tongue muscles. The following simple exercises may help improve tongue function.

Getting started

Make sure your hands are clean and your fingernails are short and filed.

Your baby should be in a quiet, alert or early active state so the exercises can be enjoyed and your baby can participate.

Do the exercises in a predictable sequence, for example, moving on when your baby shows signs of anticipating what’s coming next.

If your baby rejects the exercise, or the exercise isn’t working try a different one.

Tongue massage

For babies who find it difficult to bring their tongue forward, (as with tongue tie), this may be useful before feeding.

• Stimulate the area above the top lip to encourage your baby to open their mouth.
• Place your finger pad side up in your baby’s mouth to encourage sucking.
• Gently turn your finger over and press down on the tongue, massaging in small circular motions. (Turn your finger back over if your baby tries to suck – to be soft on the palate.)
• Continue to gently massage the tongue forward by increasing circular movements towards the front of the tongue and out of the mouth.

Gentle ‘tug of war’

To encourage babies to cup or grip with their tongue, needed to maintain a good latch onto breast or bottle.

Allow your baby to take your finger into the mouth as far as is comfortable (usually about 1/3 of the length of your finger).

When your baby starts sucking, slowly start to withdraw your finger. This will encourage your baby to grip harder, as in a gentle ‘tug of war’ game.

Press-down exercise

An exercise for babies who elevate the posterior part of their tongue (as with tongue tie) but do not like having a finger in the mouth.

• Use your fingertip to touch your baby’s chin, nose and area between top lip and nose (philtrum).
• When your baby opens the mouth in response, apply brief pressure to the area of the tongue and then withdraw quickly.
• Make silly sounds as you do this to make it fun and predictable, as well as smiling and making eye contact with your baby.
• Stop when your baby does not want to open their mouth.

Exercises following tongue tie division (as well as the above exercises)

After a tongue tie has been divided, a baby might need help to improve the forward, side to side movement and lift of their tongue.

Stick your tongue out for your baby to copy.

Stimulate the area above your baby’s top lip to encourage them to open the mouth. When the mouth opens place your fingertip on the centre of the outside of the lower gum ridge.

Maintain contact with the gum and slide your finger round to one side. Lift your finger off and return to the central position. Repeat three times to the same area.

Repeat to the other areas of the mouth, working on the lower gums first. The repetitions  give your baby a chance to follow your finger with his/her tongue.

Use your index fingers to gently lift the tongue, staying away from the wound.

If your baby becomes unsettled or distressed whilst attempting the above please stop. If they’re happy to do them try to do them as often as possible for the first 10 to 14 days following division.

It’s a good idea to do the exercises in a fun way, when your baby’s happy to participate, maybe a couple of times a day. These can be continued as needed, as your
baby grows.

For older babies, toys that encourage exploration with the tongue are helpful, and finger foods once weaning onto solids, as advised by your health visitor.

Appointment information

The infant feeding team will let you know the date and time of your appointment.

Call 07798 520830 for more information or cancellations.

Please allow time for parking and finding the venue.