This informal CPD article ‘Tongue-Tie and Breastfeeding: What Every Parent and Professional Needs to Know’ was provided by LactationGO, who support healthcare professionals in developing knowledge and skills in lactation and breastfeeding support.
Tongue-tie, known clinically as ankyloglossia, is one of the most discussed and, at times, most contested topics in infant feeding. For parents, it can be the hidden explanation behind weeks of painful, unsuccessful breastfeeding. For healthcare professionals and infant feeding specialists, it represents a genuine clinical challenge: recognising it, assessing its functional impact, and deciding whether and when to intervene.
This article explores what tongue-tie is, how it affects breastfeeding, the evidence around assessment and treatment, and what parents and professionals can do to support optimal infant feeding outcomes.
What Is Tongue-Tie?
The tongue is attached to the floor of the mouth by a thin band of tissue called the lingual frenulum. In most individuals, this frenulum allows full freedom of tongue movement. In tongue-tie, the frenulum is unusually short, tight, or anteriorly placed, restricting the tongue's range of motion.
Tongue-tie is classified into several types. Anterior tongue-tie (Types 1 and 2) is visible at the tip of the tongue and is relatively straightforward to identify. Posterior tongue-tie (Types 3 and 4) sits further back beneath the mucous membrane and is often missed on casual examination — it requires a careful manual assessment, including lifting the tongue to palpate the frenulum.
Prevalence estimates vary widely in the literature, ranging from 3% to 16% of newborns, partly because there is no universally agreed diagnostic criteria. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) and the Bristol Tongue Assessment Tool (BTAT) are among the most widely used validated tools in clinical practice.
How Does Tongue-Tie Affect Breastfeeding?
Effective breastfeeding requires a complex coordination of movements. The infant must achieve a wide latch, draw the nipple and areola deeply into the mouth, compress the breast tissue effectively with the tongue, and maintain suction throughout the feed. A restricted lingual frenulum can interfere with several of these mechanisms.
Common Signs in the Infant
- Difficulty achieving or maintaining a deep latch
- Clicking sounds during feeding (indicating loss of suction)
- Inefficient milk transfer despite prolonged feeding
- Excessive wind, colic symptoms, or reflux-like behaviour
- Poor weight gain or slow return to birth weight
- Fatigue at the breast — falling asleep quickly without adequate intake
Common Signs in the Breastfeeding Parent
- Nipple pain, compression, or misshaping after feeds ("lipstick" nipple)
- Nipple trauma, cracking, or bleeding
- Mastitis or blocked ducts related to poor milk drainage
- Feelings of incomplete breast drainage after feeds
- Oversupply in early weeks due to compensatory frequent feeding
It is important to note that not all tongue-ties cause breastfeeding difficulties, and not all breastfeeding difficulties are caused by tongue-tie. Thorough clinical assessment is essential before reaching conclusions.
NICE guideline on division of ankyloglossia
Assessment: The Importance of Functional Evaluation
A diagnosis of tongue-tie should never be based on appearance alone. What matters clinically is function, whether the restriction is causing a measurable impact on feeding.
The NICE guideline on division of ankyloglossia (NG149, 2005, updated 2021) recommends that tongue-tie division should be considered when breastfeeding difficulties are present and tongue-tie is identified as a contributing factor following thorough assessment by a trained professional.
Treatment: Frenotomy
The primary intervention for tongue-tie affecting breastfeeding is frenotomy (also called frenulotomy or division of tongue-tie). This is a quick, minimally invasive procedure in which the lingual frenulum is snipped using sterile scissors. In infants, it does not typically require anaesthetic, though some practitioners use a topical application. Laser frenotomy is an alternative approach, though the evidence base comparing laser to scissors remains limited.
A 2025 systematic review examining the prevalence of ankyloglossia among infants with breastfeeding difficulties found that approximately 34% of those presenting with feeding problems had a confirmed tongue-tie on assessment, underscoring its clinical relevance in this population (Rodriguez Lara et al., 2025).
Post-procedure, breastfeeding support from an IBCLC or qualified breastfeeding counsellor is strongly recommended. Many infants benefit from help with re-establishing latch technique following division, as habitual compensatory patterns may have developed during the restricted period.
The Role of Breastfeeding Support Professionals
Whether you are a midwife, health visitor, neonatal nurse, doula, maternity nurse, or nanny, your role in identifying early warning signs and referring promptly is invaluable. Families often present to non-specialist professionals first, and a timely, informed response can make the difference between a breastfeeding journey that continues and one that ends prematurely.
Key responsibilities for non-specialist practitioners include:
- Observing a full breastfeed and documenting latch quality and infant behaviour
- Using validated screening tools such as the BTAT as part of routine assessment
- Listening to the parent's experience. Pain that persists beyond the first few days warrants investigation
- Referring to a tongue-tie practitioner or IBCLC where tongue-tie is suspected
- Providing evidence-based, non-judgemental support throughout the process
- For those wishing to develop their knowledge in this area, structured lactation training, including specialist modules on oral anatomy, infant feeding assessment, and tongue-tie, forms the foundation of confident, competent practice.
A Note on Controversy
Tongue-tie has attracted debate within healthcare, with some practitioners questioning whether rates of diagnosis and intervention have become disproportionate. It is a legitimate professional conversation. As with any clinical area, the evidence should guide practice, and that means neither over-diagnosing nor dismissing a significant source of breastfeeding difficulty when it is genuinely present.
For families who have experienced weeks of pain, poor infant weight gain, or early breastfeeding cessation, access to skilled, evidence-informed assessment and support is not a luxury. It is a fundamental aspect of postnatal care.
Summary
Tongue-tie is a common structural variation that can significantly impact breastfeeding outcomes for both infant and parent. Effective management requires accurate functional assessment, multidisciplinary awareness, and timely referral to appropriately trained practitioners. When identified and addressed with appropriate support, many families can go on to achieve their breastfeeding goals.
Professionals at every level of the maternity and infant care workforce play a role in this, and building knowledge in lactation and infant feeding is one of the most impactful investments any practitioner can make.
We hope this article was helpful. For more information from LactationGO, please visit their CPD Member Directory page. Alternatively, you can go to the CPD Industry Hubs for more articles, courses and events relevant to your Continuing Professional Development requirements.
References
- Borowitz, S.M. (2023). What is tongue-tie and does it interfere with breast-feeding? A brief review. Frontiers in Pediatrics, 11, 1086942. https://doi.org/10.3389/fped.2023.1086942
- Knight, M., Ramakrishnan, R., Ratushnyak, S., Rivero-Arias, O., Bell, J., Bowler, U., et al. (2023). Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT. Health Technology Assessment, 27(11), 1–73. https://doi.org/10.3310/WBBW2302
- National Institute for Health and Care Excellence (NICE). (2005, updated 2021). Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance [IPG149]. London: NICE.
- Rodriguez Lara, F., Carnino, J.M. & Levi, J.R. (2025). Prevalence of ankyloglossia among infants with breastfeeding difficulties: a systematic review. Early Human Development. https://doi.org/10.1016/j.earlhumdev.2025.106286
- Rodriguez Lara, F., Carnino, J.M. & Levi, J.R. (2025). Maternal experiences and challenges in breastfeeding infants with tongue-tie: a systematic review. Maternal and Child Health Journal.
