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Improving breastfeeding outcomes: the impact of tongue-tie.


To breastfeed effectively a baby needs to be attached correctly at its mother's breast. 'Attachment at the breast' is the term used for how a baby's mouth is fixed, or appended, to mum's breast to feed. For a baby to be able to attach correctly there are two essential factors that must be in place. The first is that mum needs to offer up her baby to her breast in a manner such that he is physically able to suckle. Put more simply, it matters how she holds him, or positions him to feed.

The other crucial factor is that there is no physical reason, in the baby, why he cannot suckle. During normal suckling a baby needs to be able to extend his tongue to the lower lip to create an effective seal, along with his palate and buccal pads (cheeks), around mum's breast. Abnormalities such as a cleft palate or, the relatively less well developed buccal pads of a premature baby, can also diminish the baby's ability to create or maintain the seal.

The principles of positioning and attachment all need to be in place for efficient breastfeeding. Information on the four principles of positioning and seven principles of attachment can be accessed on the Baby Friendly website (

If a baby is tongue-tied, by definition, the frenulum is short, tight and restricts normal tongue movement. The manner the baby moves his tongue up and down during suckling is also altered by the tongue-tie (Geddes et al, 2008a). The suboptimal or lack of, ability to attach and the altered tongue movements are responsible for the signs and symptoms seen in differing combinations, in effected mother and baby dyads (see Table 1 below).

The term 'mother and baby dyad' is used advisedly. When discussing lactation/ breastfeeding, a mother and baby are seen as a dyad, or pairing. A baby that cannot feed efficiently--such as having a tethered frenulum--will adversely affect his mother's lactation. Carers must have a working knowledge of the mechanisms at play in order to guide breastfeeding through problem situations. Where a tongue-tied baby is having difficulty breastfeeding, but mother and baby are not referred to an appropriately skilled carer, the problem can escalate to the baby being under-fed, failing to gain weight (with all associated sequelae) and great distress in the mother/parents. Ultimately, the scenario is likely to result in the baby being exclusively formulated, accompanied by long-felt disappointment in the mother, at feeling she failed to breastfeed her child.


There has been controversy over whether a tongue tie is problematic to breastfeeding and whether release improves breastfeeding. This has been because the appearance of a tethered frenulum does not always accompany compromised function (Hazelbaker, 1993). Moreover early research on the topic lacked robust methodology. Case series demonstrated positive breastfeeding outcomes for these babies, but this research design is open to the influence of various forms of bias. A lack of standardised, objective assessment tools for defining a frenulum as a tongue-tie, further complicated the debate.

Alison Hazelbaker developed the Assessment Tool for Lingual Frenulum Function (ATLFF) in order to clarify the impact of a tethered frenulum in babies with breastfeeding problems, (Hazelbaker, 1993). On reliability testing, the ATLFF's first three Function items (tongue lateralisation, elevation and extension) were found reliable but other Function items relating to sucking, were less reliable, (Amir et al, 2006). It could be argued this may have been due to inaccuracies in beliefs in the 1990s, about tongue movements during breastfeeds, that have now been revised by Donna Geddes' research using submental ultra-sound scanning during breastfeeding, (Geddes et al, 2008a; 2008b).


In the 1990s it was believed a baby's tongue stripped the milk from its mother's breast with peristaltic action. Geddes et al's (2008b) research has demonstrated that this is not the case: as the tongue moves down in the mouth, negative pressure is applied to the breast, breast milk flows into the baby's mouth, the baby then elevates its tongue, returning the pressure in the mouth to baseline level and the baby swallows. The nipple is not compressed. In tongue-tied babies one of two actions occurs: either the tip of the nipple is compressed by a humping of the tongue on elevation in the mouth, or the base of the nipple is compressed on tongue elevation, (Geddes et al, 2008a). Tongue-tie release was observed to resolve or lessen this compression. The rate of milk transfer post-release was almost doubled and the mothers' 24-hour milk production quickly increased.

In an effort to respond to design critiques, researchers investigating breastfeeding outcomes following tongue-tie release, used the randomised, controlled trial (RCT) methodology. Hogan et al (2005) found 10.7% of babies born during their research appeared to be tongue-tied but only 44% of those experienced feeding problems. Consenting participants were randomised to either 48 hours of care from a lactation consultant (LC), or immediate release of the tongue tie. Only 1/29 in the LC group's breastfeeding improved, but 96% (27/28) of the release group improved. After the 48hours, all in the LC group requested the release procedure for their babies. Overall, for 95% of those that were released, feeding improved (one taking a week to improve). In the control group only 5% improved. Critique of this study focused on the lack of blinding to the intervention of the mother and breastfeeding counsellor, which may have resulted in the placebo effect artificially improving their results from frenulotomy.

Some of the above research team went on to conduct a double blinded RCT, Berry et al (2011). Participant mothers were randomised into either the release arm or non-release arm. Their babies were taken to another room for their allocated intervention. On the baby's return, each mother was asked to breastfeed her baby immediately without looking in their baby's mouth. Both the mother and breastfeeding counsellor were blind to the randomisation. The mother was asked if attachment and feeding were improved and to decide if the release procedure had been carried out.

The immediate results demonstrated that the majority of mothers correctly identified which arm of the study they had joined. Seventy-eight percent in the release group were correct and 47% in the non-release group were correct (p<0.02). Experienced breastfeeders were more likely to be correct. Breast pain scores post-intervention (prior to randomisation being revealed) did illustrate an influence of the placebo effect.

In another RCT (Buryk et al, 2011), mother and baby dyads where the tongue-tied baby (assessed using ATLFF) had been experiencing difficulty breastfeeding, or the mother experiencing nipple pain, were randomised to either the release group or sham procedure group, following written consent. The mothers in the release group had significantly better post-intervention assessment scores of their baby's competence at breastfeeding (p 0.029). A lesser placebo effect on breast pain post-procedure was found than in Berry et al, (2011), so that the release group's pain scores were significantly lower than the sham group (p<0.001).

It is apparent that all those offering support to breastfeeding mothers need to be able to assess attachment and milk transfer from mother to baby. Since NICE's decision (NICE, 2005; NICE, 2006) to support the conduct, within the NHS, of the release procedure to relieve the attachment problems a tongue-tie can cause, more trusts have developed care pathways that facilitate assessment of feeding problems, diagnosis and release of problematic tongue-ties.

Care pathway in mid-Norfolk

Since 2006 a guideline for the care of tongue-tied babies experiencing feeding difficulties has been in place within the acute NHS Trust's Maternity Services.

Where a breastfeeding baby is experiencing difficulty feeding, despite good positioning by mum, the mother and baby dyad are referred to a midwife breastfeeding-Key Worker for assessment of breastfeeding efficacy. Having addressed any remaining sub-optimal positioning, the midwife will assess for the presence of a tongue-tie, that is, whether normal tongue movement is compromised by a tethered frenulum. Should it be identified that a tongue-tie is causing the breastfeeding difficulties; a discussion takes place with the parents encompassing their choices for dealing with the problem. Where the parents wish to proceed to the release procedure, the Key Worker will complete and send a referral to the paediatric and neonatal surgeon.

While awaiting an appointment with the surgeon, the best advice will be for the mother to stimulate her breast milk production by expressing after feeds and using the milk to supplement her breastfeeds. This extra stimulation will go some way to compensating for the sub-optimal sucking action of the tongued-tied baby, until the release procedure allows normal tongue movement. Mum's supply will naturally increase to meet the baby's needs. Support appointments are advisable while awaiting the appointment with the surgeon.

Release procedure

Following the consultation between surgeon and parents and where parental consent is given, the tongue-tie is released.

The baby is brought to the appointment hungry (without feeding in the previous two hours) as this ensures the baby will open his mouth. No anaesthetic is needed for the procedure on a neonate as this would add significant, unnecessary risks to the baby. The baby is laid flat on his back, wrapped in a blanket/towel so his arms do not impede the surgeon and an assistant holds the baby's head steady. The surgeon examines the frenulum by lifting the tongue and uses sterile surgical scissors to release the tethered frenulum. There is often a small blob of blood. The mother is asked to breastfeed her baby immediately. Haemostasis is ensured before the family can leave the clinic. Parents are asked to feed back in two weeks as to whether the baby's feeding has improved, and the appropriateness of undertaking the release procedure without anaesthetic or sedation, along with any other comments/suggestions they might wish to make regarding the referral system. All babies are followed up by midwifery staff. Where a mother and baby have had a breastfeeding problem support appointments continue until the mother is confident to be discharged. Key workers in this care pathway will follow up mothers via phone calls to monitor their progress.


It is clear how uncompromised tongue movement is vital to a breastfeeding baby and how valuable Geddes and her team's research has been in understanding why tongue-ties interfere with breastfeeding. The levels of evidence now coming out of studies on tongue-tie release benefiting breastfeeding have improved as researchers have responded to scientific critique of their research methodology.

More NHS trusts are putting in place care pathways to resolve this mechanical problem that can have destructive effects on breastfeeding outcomes. Consequently, more babies born with this anomaly are benefiting from their mothers' breast milk.

No competing interests declared


Grateful thanks to Mr Ashish Minocha, Consultant Paediatric and Neonatal Surgeon (ashish.minocha@, the surgeon to whom affected mothers and babies are referred within the Norfolk and Norwich University Hospitals NHS Foundation Trust, for providing the photographs and for support in the drafting of this article.


Amir LH, James JP, Donath SM. (2006) Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J 1(1): 3.

Berry J, Griffiths M, Westcott C. (2011) A double-bind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeed Med [Epub ahead of print]

Buryk M, Bloom D, Shope T. (2011) Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics 128(2): 280-8.

Geddes DT, Langton DB, Gollow I, Lorili A, Hartmann PE, Simmer K. (2008a) Frenulotomy for breastfeeding infants with ankyloglossia: effects on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 122: e188-e194.

Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. (2008b) Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development 84: 471-7.

Hazelbaker A. (1993) The assessment tool for lingual frenulum function (ATLFF): use in a lactation consultant private practice. Pasadena, CA: Pacific Oakes College.

Hogan M, Westcott C, Griffiths M. (2005) Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health 41(5-6): 246-50.

National Institute for Health and Clinical Excellence (NICE). (2005) IPG 149 Division of ankyloglossia (tongue tie) for breastfeeding--guidance. London: NICE.

NICE. (2006) CG37 Postnatal Care. London: NICE.

Rosemary Jackson RN, RM, BSc(Hons), IBCLC, MSc

Midwife/Project Coordinator, Norfolk and Norwich University Hospitals NHS Foundation Trust

Correspondence to:
Table 1. Signs and symptoms of poor
attachment in the presence of
tongue-tie (where positioning has
been assessed as correct)

In mother In baby

Sore/painful/ Repeated loss of
 cracked nipples attachment

Misshapen nipples Clicking or
 upon detachment smacking noises
 with all or some

Poor drainage of Poor weight gain
 milk or weight loss
Mastitis Frustration at
 loss of
 attachment or
 inability to

Poor milk supply Marked windiness

Exhaustion Frequent feeds

Distress as Feeds lasting a
 breastfeeding long time
 not as (unable to take
 fulfilling as milk efficiently)
 she had
 anticipated Or short feeds
 (as baby becomes
 tired and weak)
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Author:Jackson, Rosemary
Publication:Community Practitioner
Date:Jun 1, 2012
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