Tongue-Tie in Babies: Signs, Breastfeeding and Frenotomy

You are in pain at every feed, despite the positioning advice. Baby slips off, makes little clicking noises, and the feeds never seem to end. On social media, the answer comes fast: “it's his tongue-tie, it has to be cut”. Sometimes that is true. Often it is not.

The subject divides opinion. In France, the National Academy of Medicine and twenty-two medical societies have warned about too many frenulum cuts. Here is what you need to know to have your baby assessed calmly, without missing a real problem or undergoing an unnecessary procedure.

What is a restrictive tongue-tie?

The tongue frenulum is the small membrane that joins the underside of the tongue to the floor of the mouth. Everyone has one. We speak of ankyloglossia (tongue-tie) when this frenulum is short, thick or tight enough to limit tongue movement, often because it attaches very far forward.

The Mayo Clinic specifies that it is a feature present from birth, slightly more common in boys, and sometimes running in families. Many babies have a visible or slightly short frenulum with no difficulty at all. The NHS says it clearly: a frenulum that causes no problem is not treated.

Which signs should make you think of a tongue-tie?

The signs that matter concern feeding, in baby and in you. The NHS and the Mayo Clinic cite:

In baby

• trouble latching on or staying latched;
• very long, very closely spaced feeds;
• clicking noises, coughing or choking during the feed;
• lots of milk running out of the mouth;
• small amounts at each feed, and insufficient weight gain;
• a tongue that lifts poorly, does not stick out beyond the gums, or takes a heart shape.

In the mother

• sore or damaged nipples that do not heal (see our article on cracked nipples);
• tense, swollen breasts that are poorly emptied, and sometimes a falling supply.

Careful: none of these signs is specific to tongue-tie. A poor position, a very sleepy baby or a strong let-down cause the same difficulties. French medical societies insist: you must look first for the more common causes.

Why assessment must be done by a trained professional

Diagnosis is first of all functional. A short frenulum seen by lifting the tongue is not enough: what counts is how baby sucks and swallows, and how comfortable you are during the feed.

The National Academy of Medicine asks that this assessment be done by professionals trained in breastfeeding: paediatrician, midwife, qualified lactation consultant. They watch a whole feed, examine baby's mouth and check his weight curve. The assessment grids that exist have not proved reliable, note the medical societies: clinical judgement remains central.

In Morocco, talk first to your paediatrician or the midwife who follows you. They can refer you, if needed, to a lactation consultant or an ENT or paediatric oral surgery specialist.

What to do in the meantime? First, support breastfeeding

The first response is not surgical. French medical societies reserve frenotomy for cases where breastfeeding support measures have failed. Quebec's INSPQ advises working on position and latch while waiting for the assessment.

• Change position: the semi-reclined position or the football hold often helps baby open wide. Our guide to breastfeeding positions describes them step by step, and a nursing pillow helps support baby at breast height.
• Improve the latch: mouth wide open, chin against the breast, more areola taken below than above.
• Protect your supply if baby feeds poorly: expressing your milk after some feeds keeps lactation going. Our article on expressing your milk explains how.
• Watch weight and nappies: this is the best sign that baby is drinking enough. The guidelines are in our article on low milk supply.

Many difficulties improve with these adjustments and as baby grows.

Frenotomy: when is it discussed?

A frenotomy involves cutting the frenulum with sterile scissors. In a young infant, the procedure is very brief and done without general anaesthesia, sometimes with a contact anaesthetic. Baby is put back to the breast straight away. The NHS observes that most babies feed better soon afterwards.

But French medical societies strictly limit its indication. It is discussed only:

• for an anterior tongue frenulum, short or thick;
• when it genuinely interferes with feeding;
• after breastfeeding support has failed;
• together with the paediatrician or family doctor, after parents have been told of the benefits and risks.

The Academy calls it an “exceptional” procedure. It reminds us that good-quality studies are lacking to prove that frenotomy improves milk transfer or nipple pain. The ideal age is not defined, and the laser has shown no advantage over scissors.

Posterior tongue-tie, lip-tie, laser: the excesses to know about

In Australia, the number of frenotomies has risen by at least 420% in about ten years, reports the National Academy of Medicine. French medical societies have reacted against several practices:

• “Posterior tongue-tie”: there is no consensus on its existence, and cutting it has not proved effective. They propose abandoning this diagnosis.
• Cutting the lip frenulum: no evidence that it improves feeding or pain.
• “Preventive” frenotomy, in a baby who feeds well.
• Promises without evidence: tongue-tie has not been shown to cause reflux, colic, sleep apnoea, language disorders or difficulties with solid foods.
• Exercises in the mouth after the procedure: the medical societies write that no intra-oral manipulation is needed in the following days.

They also warn against networks that offer frenotomy at excessive prices. If you are offered a laser procedure, or one on a “posterior” frenulum or on the lip, ask for a second opinion from a paediatrician.

After a frenotomy: what to watch

The procedure is simple, but not trivial. The National Academy of Medicine lists rare complications: bleeding, damage to neighbouring tissue, infection, breathing difficulty, refusing to feed or an aversion to anything touching the mouth.

In the days that follow, keep putting baby to the breast often, and get support from the professional who follows your breastfeeding. The procedure does not solve everything: position and latch still need work. If baby refuses the breast after the procedure, our article on the nursing strike will help.