Feeding difficulties in the newborn have many possible causes. Tongue tie is one of them, but so are positioning and attachment, milk supply, reflux, a sleepy or unsettled baby, oral thrush and anatomical differences in the mouth. The only reliable way to tell them apart is to have a feed watched and your baby assessed.

Tongue tie, or ankyloglossia, is present in 4% to 11% of newborns¹. That makes it common enough to be worth checking for, and it is not the explanation for every difficult feed. World Breastfeeding Week runs from 1 to 7 August, and it is a good moment to say something that often gets lost: if feeding is hard, it does not mean you are doing it wrong.

For what tongue tie is, its types and its signs, see our article on what tongue tie is and how to spot it.

What Else Can Make Feeding Difficult?

A difficult feed is more often a sign that something small needs adjusting than a sign that something is wrong.

Causes worth considering alongside tongue tie include:

• Positioning and attachment. How your baby is held, and how deeply they take the breast or teat, changes everything about a feed.
• Milk supply and flow. A slow flow can leave a baby frustrated and feeding for a very long time. A fast let-down can make them splutter, pull off or take in air.
• Reflux and wind. Bringing milk back up, arching or being unsettled after feeds can look like a feeding problem and has its own causes.
• A sleepy or unsettled baby. Babies who are jaundiced, born early or simply not awake enough at feeds can feed poorly for reasons unrelated to their tongue.
• Oral thrush. A fungal infection in your baby's mouth, or on your nipple, can make feeding sore for both of you.
• Differences in the mouth or palate. A high or unusually shaped palate can affect how well a baby makes a seal, and is worth having looked at rather than guessed at.

Our article on feeding struggles and their connection to tongue tie goes further into latch and maternal symptoms.

What Points Towards Tongue Tie?

Tongue tie is where the piece of skin connecting the tongue to the floor of the mouth is shorter or tighter than usual, and it is most common in babies [2]. What matters is not how the frenulum looks, but whether it is restricting the tongue and getting in the way of feeding.

The NHS highlights the following signs that a tongue tie may be affecting feeding²:

• difficulty attaching to the breast or bottle teat, or staying attached
• feeding for long periods, and seeming unsettled or hungry afterwards
• excessive dribbling during feeds
• coughing or choking while feeding
• taking only a small amount of milk at each feed
• losing weight, or struggling to put weight on

Sore nipples, or painful and swollen breasts, can also be part of the picture for the mother².

Every one of those signs can happen for the other reasons above too, which is why a tie is not diagnosed from a photograph or a quick look.

How Do You Tell The Difference?

By having a feed watched by someone trained to watch it. The NHS advises speaking to a midwife, health visitor or GP if you think your baby has tongue tie, or if feeding is difficult². An assessment looks at how the tongue moves, how your baby attaches, what happens during a real feed, and what else could explain it. At LivingCare, our maxillofacial specialists can carry out this assessment too.

The NHS is clear that treatment is not usually needed if a tongue tie is not causing problems². Equally, a difficult feed with no tie needs support, not a procedure. It is well known that some tongue ties can also affect speech, and the release to help feeding may prevent speech-related issues when older.

At LivingCare, tongue-tie assessment sits within our Oral and Maxillofacial service, and the release is carried out by our maxillofacial surgeons. You can see what is involved on our tongue-tie assessment and release page.

Does Releasing A Tongue Tie Fix Feeding?

Where a tongue tie is genuinely restricting feeding, releasing it can help. The NHS says that after the procedure, most babies get better quickly and are able to feed better². UNICEF UK Baby Friendly's research digest reports studies finding improvements in latch, maternal pain and feeding confidence after a division, in babies who had both a tongue tie and feeding difficulties³.

The evidence also has real limits, and it is fairer to say so. A Cochrane review of five randomised trials found that division reduced nipple pain for breastfeeding mothers in the short term but had an inconsistent effect on infant breastfeeding, and its authors concluded that definitive benefit has not been proven, given how few and how small the studies were¹. No adverse effects were reported in the trials reviewed¹.

Therefore a release is worth discussing where a tie is restricting feeding, and it is not a substitute for skilled feeding support. Whether it is likely to help your baby is a conversation for an assessment, with someone who has watched them feed.

Our article on feeding struggles and tongue tie covers the feeding support and alternatives worth trying alongside a release.

What If It Turns Out Not To Be A Tongue Tie?

Then you have an answer, which is worth having. Ruling a tie out means support can go to whatever is actually making feeding hard.

Feeding is not only about the baby. Pain and exhaustion take a real toll, and good support makes a difference to how you feel as well as to how feeds go. If you would like a general medical review alongside feeding support, our private GP service can help.

Frequently Asked Questions

Does every tongue tie need to be released?

No. The NHS is clear that treatment is not usually needed if a tongue tie is not causing problems². A release is considered when a tie is restricting the tongue and interfering with feeding, and it is discussed with you at assessment rather than assumed.

Is a difficult feed my fault?

No. Feeding is a skill you and your baby learn together, and difficulty is common. Having a feed watched early is more useful than waiting it out.

Do I need a GP referral to book a tongue-tie assessment?

No. Booking is self-pay, with no GP referral needed. If you are using medical insurance, you will need a referral letter from your GP, so it is worth confirming cover with your insurer first.

Book A Tongue-Tie Assessment

If feeding is painful, or your baby is struggling and you want to know why, our specialists can assess your baby and talk you through what they find, including whether a release is likely to help. Consultations are usually available within 24 hours, and booking is self-pay, with no GP referral needed.

Book a tongue-tie assessment

This article is general information and is not a substitute for personal medical advice. If you are worried about your baby's feeding or weight, speak to your midwife, health visitor or GP.

References

1. O'Shea JE et al. - Frenotomy for tongue-tie in newborn infants, Cochrane Database of Systematic Reviews 2017
2. NHS - Tongue-tie (last reviewed 20/03/24
3. UNICEF UK Baby Friendly Initiative - Infant health research: tongue tie