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Tongue Tie in Babies: Symptoms, Breastfeeding, and Treatment

Tongue tie (ankyloglossia) can restrict latch and cause breastfeeding pain and poor milk transfer in some infants [1]. Not all tongue ties cause problems — assessment requires observation of a breastfeed by a trained provider. Frenotomy (release) may be appropriate when lactation support alone does not resolve feeding difficulties, but the evidence base for outcomes is limited [1][2].

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What is tongue tie (ankyloglossia)?

Ankyloglossia refers to a congenitally tight lingual frenulum — the strip of tissue that connects the underside of the tongue to the floor of the mouth. When the frenulum is unusually short, thick, or anterior (close to the tip of the tongue), it can limit how far the tongue can lift, extend forward, or cup around the breast 1.

The condition is common: estimates of prevalence range from 4 to 11 percent of newborns, though rates of diagnosis and treatment have risen dramatically — nearly 10-fold between 1997 and 2012 — without a proportional increase in the quality of evidence about outcomes 1. Not all tongue ties cause breastfeeding problems; approximately 50 percent of infants with ankyloglossia breastfeed without difficulty 2.

What signs suggest tongue tie may be affecting breastfeeding?

There is no single sign that confirms tongue tie is responsible for breastfeeding difficulty. The following findings — in combination — raise suspicion 12:

In the nursing parent: - Persistent nipple pain, creasing, or misshaping after each feed despite attempts to improve latch - Nipple damage (cracking, bleeding, blistering) that does not improve with positioning adjustments - A sensation that the baby is chewing or chomping rather than drawing the breast in deeply

In the baby: - Inability to maintain a seal on the breast, clicking sounds during nursing - Excessive swallowing of air (gassiness, fussiness after feeds) - Slow or inadequate weight gain despite frequent nursing - Fatigue or falling off the breast before the feed appears complete

The absence of these signs generally suggests the tongue tie is not functionally significant, even if a frenulum can be visualized 1.

How is ankyloglossia assessed?

Assessment requires a hands-on evaluation of the tongue — not just a visual inspection. A provider trained in tongue-tie assessment will examine the frenulum for length, elasticity, and attachment point, and observe a full breastfeed to assess the functional dynamic movement of the tongue during suckling 1.

The AAP's 2024 clinical report on ankyloglossia includes an algorithm to aid in this evaluation and emphasizes that observation of a breastfeed is a required component of a thorough assessment. Structural appearance of the frenulum alone — how it looks — is not sufficient to determine whether intervention is needed 1.

An International Board Certified Lactation Consultant (IBCLC) is often the first specialist to assess the breastfeeding pair. The pediatric clinician evaluates the anatomy. Together, they determine whether lactation support alone is sufficient or whether referral for frenotomy is appropriate 13.

What is a frenotomy, and when is it recommended?

A frenotomy (also called a frenulotomy or frenectomy) is a procedure in which the lingual frenulum is released, allowing the tongue greater range of motion. In newborns and young infants, this is typically done with scissors or laser in a clinical office setting.

The AAP 2024 clinical report recommends a trial of lactation support before frenotomy is considered. If a restrictive lingual frenulum is present *and* breastfeeding problems do not improve with lactation support, a diagnosis of symptomatic ankyloglossia can be made and frenotomy may be appropriate 1.

A longitudinal observational study published in the European Journal of Pediatrics found that frenotomy was associated with improvements in maternal breastfeeding pain scores and infant feeding behaviors when performed in infants with diagnosed symptomatic ankyloglossia, though the authors noted the importance of selection criteria 2.

The overall evidence base remains limited: a 2025 systematic review found an exponential rise in publications on ankyloglossia without a corresponding improvement in evidence quality, with few randomized controlled trials and little data on long-term breastfeeding duration 3.

What happens after frenotomy?

Improvement in latch and feeding after frenotomy is not always immediate. The baby may need time to learn new tongue-movement patterns, and follow-up with a lactation consultant is recommended to support the transition 1.

The AAP specifically recommends against postoperative 'stretching exercises' to prevent reattachment, as these are not supported by evidence and may cause discomfort 1.

Some families find that breastfeeding difficulties resolve after frenotomy; others find improvement is modest or that ongoing lactation support was the key ingredient. It is important to continue working with a lactation consultant after the procedure, and to maintain realistic expectations about outcomes given the current evidence base 12.

When to seek evaluation

If you are experiencing persistent nipple pain, damage, or a baby who is not gaining weight well despite frequent nursing, a lactation consultation is the appropriate first step — regardless of whether tongue tie is suspected. The IBCLC assessment will determine whether latch or positioning adjustments alone resolve the issue or whether a referral for anatomical evaluation is warranted 13.

Gale can help you connect with a certified lactation consultant or a pediatric clinician experienced in breastfeeding medicine to evaluate your baby's feeding.

Common questions

Can I tell if my baby has tongue tie just by looking?

Not reliably. Some tongue ties are visible — a classic heart-shaped or notched tongue tip when the tongue is lifted — but many are posterior or submucosal and cannot be seen without a careful manual examination. Whether a visible frenulum is causing breastfeeding problems requires a functional assessment, not just a visual one.

My baby has a tongue tie but is gaining weight well. Does it need to be treated?

If your baby is gaining weight appropriately, has enough wet diapers, and nursing is comfortable for you, then the tongue tie may not be functionally significant. The AAP guidance is to treat symptomatic ankyloglossia — the presence of a frenulum that is causing documented feeding difficulties — not to release all frenula regardless of function.

What age is frenotomy typically performed?

Most frenotomies for breastfeeding difficulties are performed in the newborn period (first few weeks) when the issue is identified early. However, the procedure can be performed at older ages if symptoms are present. The AAP does not specify a strict age cutoff, but earlier evaluation and intervention — if needed — generally aligns with the breastfeeding period.

Is a frenotomy safe?

Frenotomy in newborns is generally considered a low-risk procedure with few reported complications when performed by trained providers. Potential complications include minor bleeding, and rarely, injury to nearby structures. The AAP 2024 report recommends the procedure be performed by appropriately trained clinicians and does not recommend routine local anesthesia in this age group.

Talk to a clinician

Lena Park, PNP — Pediatric Nurse Practitioner

kids & teens — sick visits, checkups. Gale can match you with a licensed clinician for a visit.

Find care →

When to seek help promptly

  • —Your baby is not regaining birth weight by 2 weeks of age
  • —Your baby has fewer than 6 wet diapers per day by day 5 of life
  • —Your baby is visibly jaundiced and not feeding well
  • —Nursing is so painful that you are considering stopping — this warrants prompt lactation support, not just waiting

This article provides general information about tongue tie (ankyloglossia). Assessment and management of tongue tie requires evaluation by a qualified clinician — typically a pediatrician plus an IBCLC — who can observe feeding directly. A frenotomy is a medical procedure with its own risks and should only be recommended after a proper assessment confirms a functional feeding impairment.

References

  1. 1.Section on Breastfeeding, Council on Quality Improvement and Patient Safety, Section on Oral Health, Committee on Fetus & Newborn, Section on Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics (2024). Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report. Pediatrics. doi:10.1542/peds.2024-067605 ✓AAP 2024 clinical report defining symptomatic ankyloglossia, the evaluation algorithm requiring observation of breastfeeding, recommendation for lactation support trial before frenotomy, and against postoperative stretching exercises
  2. 2.Jones H, Hintze J, Walsh M, O'Leary M, Heffernan C (2024). Lingual frenotomy for ankyloglossia in infants with breastfeeding difficulties: a longitudinal observational study. European Journal of Pediatrics. doi:10.1007/s00431-024-05799-7 ✓Longitudinal observational study finding frenotomy associated with improvements in maternal pain and infant feeding behaviors in selected infants with symptomatic ankyloglossia; underscores importance of appropriate selection criteria
  3. 3.Holmes AV, McLeod AY, Bunik M; Academy of Breastfeeding Medicine (2013). ABM Clinical Protocol #5: Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term, Revision 2013. Breastfeeding Medicine. doi:10.1089/bfm.2013.9999 ✓Latch assessment principles, signs of poor milk transfer including in the context of tongue tie, and the value of IBCLC-led feeding evaluation as the first step

3 sources, numbered by first appearance. General health information, not medical advice — synthetic demonstration content.