Tongue-tie (ankyloglossia) is a short or tight lingual frenulum that restricts tongue movement. It occurs in around 1 in 20 babies. It commonly causes nipple pain and damage, poor transfer and slow weight gain in breastfed babies — and it affects bottle-fed babies too, though less often. A full feeding assessment should always come before a tongue-tie assessment, because many of the same symptoms are caused by positioning and attachment.
Table of contents
This guide draws on Q&A material from Sarah Oakley, International Board Certified Lactation Consultant and tongue-tie specialist, who has completed over 4,000 tongue-tie procedures in the UK and is widely regarded as the go-to practitioner for tongue-tie training.
What tongue-tie is
Watch: what to look for when assessing a newborn for tongue-tie.
A lingual frenulum is a normal part of the development of the mouth and tongue. When that frenulum is short or tight, it can restrict tongue movement and lead to feeding problems. That is a tongue-tie, also known as ankyloglossia.
Tongue-ties are said to occur in around 1 in 20 babies, though studies are inconsistent because assessment criteria differ, so prevalence estimates vary.
Watch: lip-tie, and what a tongue-tie specialist wants practitioners to understand about it.
Anterior vs posterior tongue-tie: what's the difference?
The distinction matters less clinically than people assume — but it comes up constantly, so it is worth being precise.
"It doesn't really matter. If the tongue is restricted in the way that it's moving and it's impacting on feeding, then that's an indication to divide it. But people often ask what the differences are."
Sarah Oakley IBCLC and Tongue-tie SpecialistAnterior tongue-tie is attached close to the tip of the tongue and is visibly obvious. Anything attached from the tip to roughly halfway back along the underside of the tongue is generally classed as anterior. Most studies referring to anterior ties mean those no further back than the halfway point.
Posterior tongue-tie is attached further back and is not visually obvious. Often the frenulum cannot be seen at all until the tongue is physically lifted, or while the baby is crying. Anything attached from the halfway point to the base of the tongue is classed as posterior.
Posterior tongue-tie remains a controversial category, and practitioners hold genuinely different views on it.
How it affects breastfeeding
An important starting point: with the right support, most babies with tongue-tie can breastfeed. Very few are unable to feed at all.
Where problems occur, the lactating parent commonly experiences:
- Nipple damage and pain
- Misshapen or blanched nipples after a feed
- Low milk supply
- Exhaustion, and sometimes feeding aversion or agitation caused by the pain
The mechanism is straightforward: restricted tongue movement means the baby often cannot create a tight seal and vacuum on the breast, so they slip off frequently. When they are on the breast, the nipple is compressed against the hard palate. That compression causes trauma and pain.
Symptoms in the baby include excessive weight loss, fussy behaviour, colic, reflux, wind, and clicking noises during feeds.
Important: this list is not exhaustive, and many of these symptoms are equally indicative of poor positioning and attachment. A full feeding assessment by someone qualified should rule those out before a tongue-tie assessment.
Tongue-tie and bottle feeding
Tongue-tie is more likely to cause problems for breastfed babies, because they use their tongues in a more complex way than a bottle-feeding baby does. But it is a mistake to assume bottle feeding sidesteps the issue.
"Quite often we see bottle-fed babies who are having very similar issues to babies who are breastfeeding. They often don't make a very good seal on the bottle, so they're very messy. They often take in quite a lot of air because they can't maintain the suction."
Sarah Oakley IBCLC and Tongue-tie SpecialistTwo opposite patterns show up in practice. Some babies have problems with flow regulation — gulping the bottle down very quickly, then becoming uncomfortable or being sick. Others cannot generate adequate suction, so feeds take a very long time. They may take two hours to finish a bottle, or never finish it at all because they tire and fall asleep after a small amount, then feed very frequently.
Both groups are prone to wind and reflux. Switching to bottle feeding is not a solution to tongue-tie, and it needs to be taken as seriously in bottle-fed babies as in breastfed ones.
What to do if you suspect tongue-tie
Watch: the most common mistake made when a division is being considered.
A feeding assessment comes first. If that assessment raises suspicion of a tongue-tie, a further assessment by an appropriately qualified practitioner should follow.
Several assessment tools exist. In practice, a tongue-tie practitioner will use a gloved hand to explore inside the baby's mouth, assessing oral function and suction, and observing the elevation of the tongue.
You can find an IBCLC through Lactation Consultants of Great Britain, and a tongue-tie practitioner through the Association of Tongue-tie Practitioners.
Who is qualified to divide a tongue-tie
Watch: the three complications that most often arise after a division.
Division is a regulated surgical activity in the UK, and this is an area where the position genuinely changed.
When the Association of Tongue-tie Practitioners was set up in 2012, the Care Quality Commission advised that private practitioners did not need to register, on the basis that the work fell under an exemption for private nursing care. As private practice grew, the ATP raised the question again and received vague and conflicting responses, so sought legal advice and advised members to suspend private division services in the interim — a protective step, not the result of any complaint, adverse incident or risk to the public.
Following a formal request for clarification, the CQC confirmed that private tongue-tie practitioners do need to register with them for surgical procedures. The CQC's briefing is published here.
In practice this means: a private practitioner dividing tongue-ties should either be CQC-registered themselves, or working under the governance arrangements of an organisation that is. It is a fair and reasonable question for a practitioner to ask on a family's behalf.
Common questions
Watch: the emotional impact on parents, and why it matters to how you support them.
How common is tongue-tie?
Around 1 in 20 babies, though estimates vary because studies use different assessment criteria.
Does a posterior tongue-tie need dividing?
The deciding factor is function, not classification. If tongue movement is restricted and it is affecting feeding, that is the indication to divide — regardless of whether the tie is anterior or posterior.
Can a baby with tongue-tie still breastfeed?
Usually yes. Very few babies with tongue-tie are unable to breastfeed at all, and with the right support most feed successfully.
Will switching to bottles solve it?
No. Bottle-fed babies with tongue-tie commonly struggle with seal, suction, air intake, flow regulation, wind and reflux.
Want to train specifically in tongue-tie? Babyem doesn't run a standalone tongue-tie qualification. Practitioner training and division courses are run through the Association of Tongue-tie Practitioners, which is the right route if you want to assess and divide.
Recognising tongue-tie is part of the wider skill
Tongue-tie is covered as a masterclass within our OCN-accredited Maternity Nurse Training at Level 4 — alongside infant feeding, newborn care and knowing when and how to refer. It's the difference between spotting that something is wrong and knowing what to do about it.