What is a Tongue-Tie?

Tongue-tie occurs when the small piece of skin that holds the tongue to the floor of the mouth (lingual frenulum) is very tight reducing the movement of the tongue. The medical name for this is anklyoglossia, The picture here shows a baby with tongue tie.

During the early weeks of pregnancy a baby has a small piece of skin called a membrane in place to guide the development of the mouth.

As pregnancy progresses the membrane becomes thinner and remains loosely attached to the tongue and the floor of the mouth.

In tongue-tied babies this membrane has remained unusually short and tight.

Tongue-tie is more common in babies who are born prematurely, where there are other family members with tongue-tie, and in more boys than girls.

Many babies have a tongue-tie and it passes unnoticed, or may cause no problems and does not require any treatment.

For other babies it can interfere with feeding.

If your baby has a tongue-tie that is causing a feeding problem, your health professional will refer you to a tongue-tie practitioner at Colchester Hospital. This will be a specialist midwife who has had specialist training in tongue-tie assessment and separation.

Tongue-tie can affect both breast and bottle feeding. If this happens, your midwife, health visitors and support workers are available to help you.

To breastfeed successfully, the baby needs to latch on to both the breast tissue and nipple, and their tongue needs to cover the lower gum so the nipple is protected from damage. Some babies with tongue-tie cannot open their mouths wide enough to latch on to their mother’s breast properly. For this reason, they tend to slide off the breast and ‘chew’ on their mother’s nipple with their gums.

This can result in a poor latch at the breast causing the mother pain, with sore nipples that may become damaged and may bleed.

Some babies will be unable to feed well and can get tired, but they soon become hungry and want to feed again. Often, these feeding difficulties mean the baby fails to gain much weight.

If your baby is breastfeeding, they may:

• have difficulty latching on to your breast
• have difficulty in staying on your breast
• cause painful feeds
• be feeding for a long time
• fall asleep during feeds
• be unsettled and seem hungry
• not gain weight as expected
• make clicking noises
• suffer with colic, wind, hiccoughs
• have reflux (vomiting after feeds).

If the tongue-tie is affecting breastfeeding, you may have:

• sore nipples
• misshapen nipples after feeding
• lumps in your breast (blocked ducts)
• pain, swelling and/or redness of the breast and possibly flu-like symptoms (mastitis)
• a low or decreasing supply of milk breasts that do not feel emptied after feeding.

The presence of a tongue-tie may not be causing these problems.

Your midwife or support worker can advise you on breastfeeding and on the way your baby is positioned during feeds.

Possible effects on bottle feeding Tongue-tie may also affect your baby’s feeding if they are bottle-fed.

They may:

• find it difficult to bottle feed
• take a long time to feed
• drink only small amounts
• dribble a lot of milk during feeds
• make clicking noises
• have colic, wind, hiccoughs
• have reflux (vomiting after feeds).

In addition, if you are using a dummy your baby may not be able to keep it in their mouth.

If your baby has been diagnosed with a tongue-tie that is affecting their feeding, you will need to decide how it should be treated.

Your options are:

• do nothing and continue with feeding support and see if your feeding problem improves
• be referred to an assessment clinic for further discussion.

If you choose to be referred, your midwife or health visitor will perform a feeding assessment and complete the referral form.

Following receipt of the referral you will be contacted via telephone within one week.

During the telephone discussion an assessment will be made of the following:

• the way your baby’s tongue moves
• the way the your baby is feeding
• what happens next.

You do not need to make a decision straight away.

You may be offered an appointment at the tongue-tie assessment clinic. At this appointment your baby will be assessed for tongue-tie using a clinical scoring tool.

• If your baby has a significant tongue-tie it can be separated at this appointment. The medical name for this is a frenulotomy. You can decide not to have your baby’s tongue-tie separated.
• If your baby does not have a significant tongue-tie you will not be offered separation.

In either case, we will give you information about how you can get support in your area with feeding your baby.

To have an appointment at the tongue-tie clinic, your baby must be fit and well and not awaiting any investigations or follow-up hospital appointments, or be on any medication. This will be discussed during your telephone consultation.

As your baby grows, so does the mouth and the tongue. As the tongue moves it is possible for the tongue-tie to separate spontaneously. This may occur during childhood or even when an adult.

You can ask your health visitor, community midwife or GP for advice at any time and they may refer your baby to the midwife-led tongue.

tie assessment service at Colchester Hospital if your baby is below 12 weeks. If your baby is over 12 weeks, your GP can refer to an Oral/ENT surgeon.

Please note that the Midwife-led Tongue-tie Assessment service at Colchester Hospital cannot accept referrals if your baby has already had a division of tongue-tie (frenulotomy) performed by another tongue-tie (frenulotomy) service.

For babies up to 10 weeks old (from your expected date of delivery), if you decide you would like your baby to be assessed and considered for a frenulotomy, you need to contact your health visitor or GP.

You can either: 

• ask your GP to refer to you to the midwife-led tongue-tie assessment service at Colchester Hospital 
• ask your GP to refer your baby to an Ear, Nose and Throat (ENT) or Oral specialist consultant at hospital 
• find a local specialist tongue-tie practitioner on the Association of Tongue-tie Practitioners’ website at www.tongue-tie.org.uk (This is not an endorsement of any practitioners on this site.) 

If your baby is older than 10 weeks of age (from your expected date of delivery) ask your GP to refer your baby to an Ear, Nose and Throat (ENT) or Oral specialist consultant.

A tongue-tie separation is a simple and quick procedure. It can be performed either while you and your baby are on the maternity ward or as an outpatient at the tongue-tie clinic.

Your baby will be wrapped in a towel to keep them still. They will then be placed on a bed and a light will be used to look into your baby’s mouth. Blunt-ended, curved scissors are used to cut the tongue-tie You will be able to be with your baby at all times.

Your baby may cry during the procedure and afterwards for a short time and there will be a small amount of bleeding when the tongue- tie is cut.

When the tongue-tie has been cut, it opens into a diamond shape at the base of the tongue. This seals over quickly and then becomes a white patch which looks a bit like an ulcer. This gradually gets smaller and heals over a period of 1-2 weeks. If your baby is jaundiced, it will be yellow.

After the frenulotomy, you will be expected to feed your baby; this helps control any bleeding. For most babies, there is an immediate improvement in feeding although it may take longer in some babies and take up to two weeks.

Immediately after the procedure, babies should be offered a feed. This is a way you can give comfort to your baby. Babies can be unsettled for 24-48 hours after the frenulotomy. We recommend lots of skin contact and cuddles. In some cases your baby may need pain relief.

Pain relief options available: For babies under eight weeks: Paracetamol medicine may be prescribed by a GP.

For babies over eight weeks: Paracetamol (such as Calpol) can be given without a prescription (always read the label and do not exceed the recommended dose).

There is usually only a little bleeding. Experience has shown that sometimes the wound can bleed slightly for up to 24 hours after the frenulotomy. The bleeding normally settles on its own with no further treatment or long-term effects on your baby.

Before you leave the clinic, the tongue-tie practitioner will check there is no bleeding from the wound and give you information on caring for your baby after a tongue-tie separation.

If the wound starts to bleed once you and your baby get home feed your baby for at least 15 minutes as this helps to stop bleeding.

Or

• Apply continuous pressure for five timed minutes under the tongue on the diamond-shaped area (wound) with a clean, dry cloth or gauze swab. Do not use cotton wool. The bleeding should stop. If you cannot apply pressure directly to the wound, press down firmly on the tongue itself above the wound site.
• If after five minutes the bleeding has not stopped, use a fresh clean, dry cloth or swab and apply continuous pressure to the wound again, for another five timed minutes. Make sure you are applying pressure to the wound. Hold the cloth or swab at all times – do not leave it in your baby’s mouth without holding it.

If after feeding or applying pressure the bleeding has not stopped, or if at any time you are concerned about your baby’s wellbeing, we advise you to either: • contact a tongue-tie practitioner. To do this, call 01206 5042032 Monday to Friday, 9 am-2.30 pm or • go to your local Emergency Department (ED). Keep continuous pressure under your baby’s tongue using a clean cloth or swab until the bleeding has stopped or you have arrived in the ED.

When you arrive at the ED, give staff the letter you have been given by your tongue-tie practitioner. This letter may have been put in your Red Book.

As with any operation, there is a small risk of infection. After the procedure, if your baby shows any signs of infection such as a high temperature, not feeding well and they are unsettled, it is important to contact your GP for advice.

In some babies, the tongue-tie may reform. You may notice changes in your baby’s feeding and if this happens you should either: 

• email a tongue-tie practitioner at chu_ftr.tonguetie.nhs.net and they will contact you within seven days of receiving your email or 
• you can contact your health visitor, community midwife or GP.

You should care for your baby as normal. Some research suggests that it may help your baby’s tongue movement and reduce the risk of reformation if you encourage your baby to poke its tongue out. The midwife who performs the frenulotomy will discuss this with you after the procedure.

You can find out more from the following web links: 

• NICE Guideline available at www.nice.org.uk/IPG149publicinfo 
• Association of Tongue-tie Practitioners www.tongue-tie.org.uk 
• UNICEF http://www.unicef.org.uk/BabyFriendly/ (search for tongue- tie) 
• Milk Matters http://milkmatters.org.uk/international-service-tongue- tie-talk/ 
• La Leche League GB http://www.laleche.org.uk/ 
• Breastfeeding Network http://www.breastfeedingnetwork.org.uk/ 
• Association of Breastfeeding Mothers http://abm.me.uk/frenulotomy-tongue-tie-release/ 
• Baby Centre http://www.babycentre.co.uk/a552046/tongue-tie 
• NH Choices http://www.nhs.uk/Conditions/tongue-tie/Pages/Introduction.aspx

If you have any questions, or if there is anything you do not understand about this leaflet, please contact a tongue-tie practitioner.

To do this, phone 01206 742032, 01206 742779 or 01206 742421. 

This service is available Monday to Thursday, 9.00 am -2.30 pm For non-urgent queries you can email a tongue-tie practitioner at: chu_ftr.tonguetie.nhs.net You will be contacted within seven days.