It is incredibly common to be told your baby “has a tongue-tie” when you are experiencing breastfeeding difficulties, nipple pain, clicking, fussing or a baby who seems unsettled at the breast.

And once someone points it out, it can be difficult to unsee.

Suddenly, you may find yourself wondering:

Is this why breastfeeding hurts? Is my baby getting enough milk? Do we need a tongue-tie release? Will things get worse if we don't do it?

Let's simplify what actually matters.

Not every frenulum is a tongue-tie

Many babies are born with a visible lingual frenulum, the fold of tissue underneath the tongue.

This is normal anatomy, and its appearance varies considerably between babies.

A frenulum that looks prominent, or thick does not automatically mean that it is causing a breastfeeding problem.

Current clinical guidance recommends looking at tongue function and breastfeeding function together, rather than diagnosing ankyloglossia from appearance alone.

So what actually matters?

A clinically significant tongue-tie should involve:

• A restrictive lingual frenulum
• Reduced tongue movement or function
• A clear breastfeeding problem associated with that restriction
• Breastfeeding difficulties that have not improved with appropriate breastfeeding support

This is sometimes described as symptomatic ankyloglossia.

In other words:

A frenulum is an anatomical finding. A tongue-tie becomes clinically important when it is actually affecting function.

Most breastfeeding problems have more than one possible cause

Nipple pain, clicking, slipping off the breast, long feeds, fussiness, poor milk transfer and difficulty maintaining attachment can all occur with a restrictive tongue.

But they can also occur for many other reasons.

For example:

• Positioning
• Attachment
• Infant body alignment
• Milk flow
  
• Feeding coordination
• Infant oral-motor skills
• A baby becoming overtired or unsettled
• Difficulty maintaining a stable position at the breast

This is why a complete breastfeeding assessment should come before deciding that a frenulum is the problem.

The American Academy of Pediatrics (AAP) specifically recommends evaluating and treating other causes of breastfeeding difficulties before considering frenotomy. 

What about posterior tongue-ties?

This is where things become particularly confusing for parents.

You may have been told your baby has a “posterior tongue-tie”, sometimes based on the appearance or feel of the tissue underneath the tongue.

However, there is currently no universally accepted definition or diagnostic criteria for posterior ankyloglossia.

The 2024 American Academy of Pediatrics clinical report notes that the term is poorly defined, and recommends that it should not be used on its own as a reason for surgical intervention.

That does not mean that every baby described as having a posterior tie is feeding perfectly.

It means we need to look at the actual function of the tongue and the breastfeeding problem, rather than assuming that a particular anatomical label explains everything.

What about lip ties and buccal ties?

You may also have heard about:

• Upper lip ties
• Buccal ties
• Cheek ties

The upper lip frenulum and buccal frenula are normal oral structures found in infants.

Current evidence does not support routinely releasing these structures to improve breastfeeding. The AAP notes that there is no evidence supporting surgical intervention for labial or buccal frenula to improve breastfeeding.

This is particularly important because visual grading systems for upper lip frenula have not been shown to reliably predict breastfeeding problems.

So a prominent upper lip frenulum does not automatically mean your baby's latch, milk transfer or breastfeeding experience is being affected by it.

Before considering a tongue-tie release, look at the breastfeeding first

This is perhaps the most important part.

If breastfeeding is painful or ineffective, let me watch the feed.

Its important to look at your baby's position

Is your baby well supported and able to maintain a stable position against your body?

Attachment

Can your baby achieve and maintain a comfortable, deep, effective attachment?

Tongue function

Can your baby extend, elevate and move their tongue appropriately during feeding?

Milk transfer

Is your baby effectively removing milk from the breast?

Milk flow

Is your baby struggling with a very fast or very slow milk flow?

Your comfort

Are you experiencing persistent nipple pain or nipple damage?

These questions tell us considerably more about breastfeeding function than the appearance of a frenulum alone.

Could positioning make a bigger difference than you think?

Absolutely.

A baby who is poorly supported or struggling to maintain their position may slip on and off the breast, click, gulp, become frustrated or have difficulty maintaining effective milk transfer.

Sometimes, improving body-to-body support, positioning and attachment can make a remarkable difference.

Laid-back breastfeeding can be particularly useful for some babies because it allows the infant to use their natural reflexes while remaining well supported against the parent's body.

The goal isn't to find one magical breastfeeding position.

It is to find the position that allows your baby to remain stable, comfortable and effective at the breast.

Why are more babies being diagnosed with tongue-tie?

The diagnosis of ankyloglossia and the use of frenotomy have increased substantially in recent years.

However, the increase does not necessarily mean that more babies are suddenly being born with clinically significant tongue restriction.

There is considerable variation in how tongue-tie is defined, assessed and treated, and there are currently no universally accepted diagnostic criteria. This makes it difficult to distinguish anatomical variation from clinically significant ankyloglossia.

This is one reason current guidance encourages a functional assessment and skilled breastfeeding support before surgery.

Does tongue-tie release improve breastfeeding?

This is where the evidence becomes nuanced.

Frenotomy may provide short-term improvement in maternal nipple pain for some breastfeeding mothers. However, the evidence that it consistently improves other breastfeeding outcomes, such as milk transfer, breastfeeding duration or exclusive breastfeeding, is more limited and mixed.

The recovery period is also important to consider.

Following a frenotomy, some babies may experience pain, oral discomfort or temporary changes in their feeding behaviour. This can make breastfeeding more difficult while they recover. If a baby is feeding less frequently or removing less milk from the breast during this period, there may be less breast stimulation and milk removal, which can affect maternal milk supply.

For some families, this can create a difficult cycle:

Less effective breastfeeding → less breast stimulation → reduced milk production → increased need for supplementation.

For a mother who is hoping to exclusively breastfeed, this can be particularly stressful and may contribute to an earlier transition to formula.

This does not mean that frenotomy should never be considered. For a baby with a clearly restrictive frenulum, known as classic tongue tie, that is demonstrably affecting breastfeeding, and where appropriate breastfeeding support has not resolved the problem, a frenotomy may be a reasonable treatment option.

But the procedure should not be viewed as a quick fix for every breastfeeding difficulty.

The breastfeeding support before, during and after the procedure matters too. Protecting milk supply, maintaining effective breast stimulation and helping your baby return to comfortable, effective feeding can all be important parts of the process.

If your baby has already had a tongue-tie release

If you've already been through a tongue-tie revision and breastfeeding is still difficult, please don't assume that the procedure has failed or that another tie needs to be found.

There may be another piece of the puzzle.

Your baby's positioning, attachment, milk flow, oral-motor coordination, feeding behaviour, growth or your own breast anatomy may still need to be assessed.

And if you are considering another procedure, or weaning from breastfeeding a fresh, comprehensive breastfeeding assessment can be incredibly valuable before making that decision.

I also understand how emotionally difficult this can be.

When your baby is uncomfortable and breastfeeding isn't going the way you hoped, you naturally want to find the thing that is wrong and fix it.

That instinct comes from wanting to help your baby.

But sometimes the answer isn't another procedure.

Sometimes it is better support, better positioning and a better understanding of what is actually happening during the feed.

If you have ongoing concerns about a tongue-tie

If you are still concerned about a possible tongue-tie, start with the breastfeeding relationship, not the frenulum.

First, focus on optimising breastfeeding position, attachment, body-to-body stability and nervous system regulation. Many babies with a visible frenulum breastfeed beautifully without any form of revision.

A procedure should only be considered when there is a clearly restrictive frenulum with demonstrable functional impact on breastfeeding, and when appropriate breastfeeding support has not resolved the difficulties.

If a procedure is being considered, I believe assessment should look beyond the mouth alone. A multidisciplinary approach can help build a much clearer picture of the whole feeding system, including feeding, oral function, airway, breathing and regulation.

This may include:

1. A qualified NDC-accredited practitioner

A practitioner experienced in neuroprotective developmental care and breastfeeding, such as myself, can observe your baby feeding at the breast, rather than simply looking underneath the tongue.

This includes assessing positioning, attachment, stability, feeding coordination, milk transfer and your baby's ability to remain regulated during the feed.

2. An ENT surgeon

Where there are concerns about breathing or airway function, an ENT assessment can provide valuable information about the nasal airway, breathing pattern and effort, vocal quality and upper airway anatomy.

Airway and breathing difficulties can influence how a baby coordinates feeding, breathing and swallowing, so these factors deserve consideration when feeding concerns are complex.

3. A speech-language therapist

For some babies, a feeding assessment with a speech-language therapist can provide additional insight into oral function, sucking and swallowing coordination and feeding safety.

Look at the whole baby, not just the tongue

A frenulum is only one piece of a much bigger feeding picture.

When breastfeeding is difficult, the goal should be to understand why it is difficult before deciding what needs to be changed.

A whole-baby assessment can help you get the right information, the right support and a clearer understanding of whether a procedure is genuinely warranted.

Because before we revise the tongue, we should first understand the whole baby.