Restrictive Frenulum (Tongue Tie)

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Restrictive Frenulum (Tongue Tie)

What is tongue tie?
A tongue tie is when your baby’s tongue movement is restricted, caused by a short, tight or thickened membrane (lingual frenulum). This piece of skin under the tongue may be attached at, or close to the tongue tip, and may make the tongue look forked or have a heart shape.

A posterior tongue tie (sub-mucosal tongue tie) is located further back under the tongue and is often hidden, making it harder to see.

During your baby’s development this membrane is there to guide the shaping of your baby’s mouth. Towards the end of your pregnancy, this section of skin normally thins out, towards the back of the tongue. This may not happen for a range of reasons, for example when babies are born early.

Research suggests that approximately 1:10 babies may be born with a tongue tie, but only half these babies may need treatment.

Indications that your baby may have a tongue tie:

  • Breast or bottle-feeding difficulties which do not resolve with feeding support.
  • Baby struggles to poke their tongue out past the gum line or lower lip.
  • Baby struggles to lift their tongue to the roof of the mouth, you can see this when your baby cries.
  • Baby may have a heart shaped tongue, or a dimple in the centre, at the tip of the tongue.

These may be signs that your baby has a tongue tie, however a tongue tie can only be diagnosed after a full discussion about your feeding history and an oral assessment with a specialist tongue tie practitioner/midwife.

How can tongue tie affect your baby?
Some babies have a visible frenulum, but they may not necessarily be tongue tied if the function of their tongue is good. When their tongue movement is restricted it can affect their ability to breast or bottle feed effectively.

Because the research does not show a clear link between tongue tie and speech problems later in life, we only offer assessments when there are feeding difficulties present.

Problems which may be due to a tongue-tie.
For Baby:

  • Difficulty attaching to your breast or bottle
  • Difficulty in staying attached to breast or bottle
  • Prolonged feeding (more than 40 mins).
  • Frequent feeding (more than 12 feeds in 24 hours)
  • Not gaining weight as expected
  • Make clicking noises
  • Suffer with wind, hiccups or colic symptoms
  • Reflux symptoms
  • Dribbles milk when feeding
  • Not able to keep a dummy in (if you are using one)

For you:

  • Painful, sore, damaged or bruised nipples
  • Misshaped/blanched nipples (after feeding)
  • Lumps in your breast (blocked ducts) or engorgement
  • Mastitis
  • Low milk supply
  • Frequent feeding
  • Difficulties with establishing breastfeeding

Your baby may not have all the above symptoms and there can be other causes for these issues. It is therefore important to seek support with feeding from a midwife, health visitor, or breastfeeding support worker. Local breastfeeding support groups are also available for you to attend.

What do I do if I suspect my baby has a tongue tie?

We will only perform an assessment and division of a tongue tie in babies that are under 16 weeks.

You can self-refer to the tongue tie clinic to have an assessment. Please complete online referral form found at: Infant feeding – Worcestershire Acute Hospitals NHS Trust. Alternatively, your midwife health visitor or breastfeeding support worker can do it for you.

Once the referral has been received, one of the infant feeding team will call you to discuss your current feeding issues. We aim to do this within a week of receiving the referral. The next available appointment in the tongue tie clinic will be offered, if we feel you or your baby has feeding difficulties related to tongue tie.

What happens in tongue tie clinic?
Your clinic appointment will be with a specialist midwife, and it will last approximately 45 minutes. The midwife will discuss any feeding problems with you and explain the potential benefits and risks of a tongue tie division (frenulotomy).

What are the risks to your baby having a frenulotomy?

  • Pain – most babies do not require pain relief following frenulotomy, but older babies (above 8 weeks) can be given simple paracetamol. If your baby is under 8 weeks and you think they require paracetamol, this must be prescribed by a GP. Breast milk also contains pain relief for your baby.
  • Bleeding – Is usually minimal and normally settles on its own with a feed. Approximately 1:1000 babies may bleed for longer than expected.
  • Infection – Evidence has shown that only 1:11,000 babies have a wound infection that required antibiotics. Breast milk contains anti-infective properties that can help prevent infection.
  • Damage – to the tongue and surrounding tissues is rare and cannot do any long-term damage. This will heal very quickly.
  • Unsettled baby – your baby may be fussy at the breast or bottle whilst they build the strength in their tongue muscle.
  • Reformation – There are occasions when the wound heals so well that scar tissue forms causing a restriction that can have the same effect on feeding as before the procedure. This happens in approximately 4:100 cases.

What happens next?
Your baby will be swaddled in a towel and their head supported by a maternity support worker. The specialist midwife will examine the function of your baby’s tongue and discuss if your baby has a tongue tie or not. A frenulotomy will be offered if your baby has a tongue tie, but it is your choice. The division will be completed during this appointment if you would like it done.

If you choose for your baby to have a frenulotomy it is a simple, quick procedure which releases the frenulum under the tongue. The tongue is elevated to reveal and stretch the frenulum. Sharp, blunt ended scissors are used to cut the frenulum. Immediately after, you will offer your baby a feed.

You can use a decision making tool called B.R.A.I.N.S, to help you decide what is best for you and your baby.

  • Benefits – what are the benefits of having this procedure?
  • Risks – what are the risks of having this procedure?
  • Alternatives – are there any alternatives?
  • Intuition – how do I feel? What as parents do we think?
  • Nothing – what if I decided to do nothing / wait and see what happens?
  • Space – time and space to consider the options if needed

Effectiveness of treatment

NICE states that current evidence suggests that there are no major safety concerns about division of tongue-tie (ankyloglossia), and limited evidence suggests that this procedure can improve breastfeeding.

It must be remembered that no medical treatment or procedure is effective for all, and tongue-tie may not be the only factor interfering with feeding. Birth trauma, milk supply issues, illness in the mum, prematurity, or illness in the baby are just examples of factors that can co-exist alongside tongue-tie and impact on feeding.

All these issues need to be addressed too, access to skilled infant feeding support is essential after the procedure.

After the Frenulotomy?
You should care for your baby as normal, with lots of comfort and cuddles. After the procedure, you will be given information on what to expect in the coming days and weeks, along with a leaflet to take home.

Research
Berry J, Griffiths M, Westcott C. A double-blind, ws controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeeding Medicine, 2012, 7: 189-193.

Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics, 2011; 128: 280-286.

Cordray H, Raol N, Mahendran GN, Tey CS, Nemeth J, Sutcliffe A, Ingram J, Sharp WG. Quantitative impact of frenotomy on breastfeeding: a systematic review and meta-analysis. Pediatr Res. 2024 Jan;95(1):34-42. doi: 10.1038/s41390-023-02784-y. Epub 2023 Aug 22. PMID: 37608056.

Useful Resources

Breastfeeding support can also be accessed on the following telephone helplines:

  • On evenings and weekends calls will be redirected to The National Breastfeeding Helpline 0300 100 0212 available from 9:30am-9:30pm
  • NCT helpline 0300 330 0700 from 8am-midnight
  • La Leche helpline 0345 120 2918 from 8am-11pm

Breastfeeding Support Workers in Worcestershire
https://www.startingwellworcs.nhs.uk/breastfeeding-support-workers

To discuss a referral, please call ( office hours Mon-Fri )
01905 760507
Or visit
https://staging.worcsacute.mixd.co.uk/maternity-services/infant-feeding/

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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