If the baby cannot stick his tongue out past his bottom lip, this suggests he has a short frenulum (tongue tie). Difficulties with attachment, painful breast-feeds, sore nipples or poor infant weight gain as a result of poor milk transfer can be the direct consequence of a tongue-tie. However, approximately 50% of tongue-ties are asymptomatic and cause no problems with breast-feeding. Even if attachment is difficult, babies can still receive expressed breast milk while they await tongue-tie division. Clinical evidence supports the safety of division of tongue-tie, but there is currently little evidence to confirm that this procedure improves the breast-feeding experience.

Steps to follow 1. Assess attachment and feeding, to determine whether the frenulum is interfering with breast-feeding. If the baby is attaching adequately, the tongue-tie does not need to be divided and the feeding problems may have other causes.

2. To help babies with a short frenulum learn to extend their tongue, encourage them to lick by putting drops of milk on their lips or expressing milk onto the mother’s nipple and offering it to them. Massaging the frenulum can also help.

3. A nipple shield may help: it pushes the nipple further into the baby’s mouth than soft breast tissue alone. It may also help the baby to feel the right stimulation to start sucking effectively and stay attached more consistently.

4. Observe the baby’s tongue. Assess whether he can stick his tongue out past his bottom lip. If he cannot, this suggests a short frenulum, which would make it difficult for him to latch onto the breast, but able to suck from a finger or teat

5. If attachment is inadequate, arrange a GP consultation in case specialist referral is necessary. The baby can receive expressed breast milk while waiting for tongue-tie division, if this procedure is warranted.
Continue to provide breast-feeding support while the baby waits for division of the tongue-tie; babies can receive expressed breast milk even if attachment is impossible. Support will also be needed after the division has taken place, to help overcome attachment difficulties and promote successful breast-feeding, especially if the baby has been bottle-fed.

General references
Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lactation 2004; 20(4): 409–414.

Hogan M, Westcott C, Griffiths M. Randomised controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005;  41(5-6); 246­–250.

National Institute for Health and Clinical Excellence. (2005) Division of Ankyloglossia (Tongue Tie) for Breastfeeding – Guidance. Interventional Procedure Guidance 149, 2005. www.nice.org.uk. Accessed 12 Nov 2009. 

Wallace H, Clarke S. Tongue tie division in infants with breast feeding difficulties. Int J Ped Otorhinolaryngol 2006; 70(7): 1257–1261.

From: Journal of Family Health Care Bulletin. Directory of Breast-Feeding Advice. December 2009. Published with JFHC 2009; 19(6). http://www.jfhc.co.uk/images/stories/breastfeeding.pdf