Tongue-tie and Breastfeeding

21 hours ago

5 min read

Tongue-tie and Breastfeeding, postérior tongue-tie, tethered oral ties, or buccal ties, and lip tie-too

Breastfeeding is a natural act, but it isn't always instinctive. We often hear that "breastfeeding shouldn't hurt." That's true. And yet many mothers grit their teeth through every feed, watch their baby become agitated, or worry about slow weight gain.

Very often, they're told that their baby has a "tight tongue-tie," a "posterior tongue-tie," or even a "lip-tie" that's supposedly causing these difficulties. There is a huge amount of misinformation on this topic, with treatment approaches based on low-quality evidence.

What is a tongue-tie?

Everyone has a lingual frenulum (that small membrane under the tongue). However, in some babies, this tissue is too short, too thick, or too tight, leading to nipple pain or an inefficient feed.

Signs of a restrictive tongue-tie (ankyloglossia)

Restrictive tongue-ties can show up in many different ways. Here's a list of common symptoms to help you make sense of it.

In the mother:

Nipple pain: cracking, pinching, intense pain during feeds.
Misshapen nipples: the nipple comes out wedge-shaped (like a fresh lipstick tube) or flattened after the feed.
Lactation problems: unexplained drop in milk supply (because the breast isn't drained properly), or recurrent engorgement/mastitis.

In the baby:

Latching difficulties: frequently losing the latch, seeming to "slip off," or unable to maintain a good seal.
Clicking sounds: you hear "click-click" or air noises while nursing. A restrictive tie isn't the only possible cause of this clicking, and clicking isn't always a problem.
Fussiness and fatigue: baby gets frustrated at the breast, arches, or falls asleep quickly from exhaustion only to wake up hungry shortly after.

Note that all those signs can have other causes, and maily the position and latch at the breast.

History and myths around tongue-ties

In 2020, there was a sharp rise in diagnoses of tight tongue-tie — a clearly visible anterior tie, or a "posterior tie" hidden under the mucosa — along with treatment protocols that included: massage under the tongue before the frenotomy, frenotomy (cutting the membrane), often by laser, followed by massage under the tongue "to prevent the tie from reattaching and to improve sucking." Lip-ties and buccal-ties were also being diagnosed and put forward as the cause of current breastfeeding problems, reflux, or future issues such as jaw development problems or speech problems.

I was one of the first in France to speak out against this situation in this article, as well as against the lack of regulation in France around these practices and the lack of a clear diagnostic tool (hence the associated overdiagnosis).

Indeed, a frenotomy is not a trivial procedure, and we saw parents drawn into costly journeys to have procedures done in Paris or Bordeaux, with no improvement — and sometimes babies who refused the breast because all that intraoral massage had been intrusive.

These were followed by anatomical studies of the tongue-tie by Mills in 2019, which clarified the anatomical structure of the lingual frenulum and called into question the existence of a submucosal "posterior tongue-tie."

Then came international recommendations:

From the American Academy of Pediatrics
From the Academy of Breastfeeding Medicine

And French recommendations:

From the Académie de médecine
From the Société Française de Pédiatrie
A joint statement from learned societies on this topic

A summary of these recommendations would be as follows:

Only anterior tongue-ties that are clearly visible and causing symptoms in the mother or baby require treatment, if adjustments to breastfeeding positioning are insufficient.

The posterior tie (hidden under the mucosa) does not require intervention: this label has been called into question by the 2019 Mills studies and should no longer be used.
Cheek-ties and lip-ties: the impact of lip-ties on breastfeeding has not been demonstrated; lip-ties are a normal anatomical variation and do not require frenotomy. Cheek-ties are likewise a normal anatomical variation, and there is no benefit to cutting them.
Sucking blister: a blister on the upper lip is not a sign of a tie — this is a widely spread myth.
There is no evidence of digestive symptoms linked to a tight tie: the idea that a lot of gas, "colic," or reflux (GERD) results from swallowing air while feeding is not proven. I'll point you to this article on infant crying and the causes of colic, which shows the commercial exploitation tied to this topic.
Sublingual massage and manual therapies: manual therapy sessions and massage under the tongue have not shown to be effective... no consensus conference recommends them.

Massaging a wound prevents the healing process. Nursing at the breast is the only therapy needed after a frenotomy. Some authors even point to a possible risk of oral aversion from intraoral massage. See this article on the subject.

Frenotomy method: laser or scissors. Some families travel hundreds of kilometers because they were referred to a practitioner who cuts the tie with a laser. There is no evidence that laser is superior to scissors.

Adverse effects following a frenotomy

The Academy of Breastfeeding Medicine notes that in the case of a deep incision (deeper than for a standard tongue-tie release), there is a risk of: bleeding, hematoma, injury to surrounding tissue, or nerve injury with paresthesia and tongue numbness. Pain following the procedure can lead to oral aversion. The authors mention a published case of oral aversion associated with a staph wound infection, as well as several reported cases of significant hemorrhage — showing the serious complications that a frenotomy can potentially cause.

Following these French recommendations and position statements aimed at preventing unnecessary frenotomies, practices have shifted. Manual therapists have incorporated these recommendations... and now offer preventive intraoral massage, meant to avoid frenotomy by stretching the intraoral tissues. As a result, I now meet parents who have received a diagnosis of posterior tie for their fussy baby, with a recommendation for intraoral massage. These massages are controversial: I explain why in this article.

Why see a lactation consultant?

A tight tongue-tie is one possible cause of breastfeeding difficulties — but not the only one. It is often overdiagnosed, and very often nipple pain, suboptimal weight gain, fussiness at the breast, or crying are not actually related to the tie but to other factors that weren't taken into account. In that case, the tight tongue-tie is an association, not a cause — treating it will not improve the situation.

During a consultation:

We adjust the breastfeeding position so it's as effective and as pain-free as possible. The Gestalt position, developed by Dr. Pam Douglas, has shown effectiveness in a 5-case study for reducing pain in cases of ankyloglossia and improving latch and baby's stability at the breast.
Using a nipple shield can also relieve pain when necessary.
We optimize milk production with pumping if needed, and offer supplemental feeds for baby if weight gain is too slow.

NB: An IBCLC lactation consultant who is not a physician is not authorized to diagnose tight tongue-tie — this is a medical diagnosis. She can refer you to a doctor if there's any doubt.

Bibliography

Académie américaine de pédiatrie : prise de position en juillet 2024: voir cet article de mon blog
Communiqué De l’academie de medecine 2022
Mise en garde de plusieurs organisations et societes savantes (2022)
Academy of Breastfeeding medicine: position statement on ankyloglossia, avril 2021
Clinical consensus statement -ankyloglossia in children, Messner and al, 2020.
Mills and all, Clinical anatomy, 2019.
Ankyloglossia and oral frena Consensus statement, Australian dental association, 2020.
Cochrane review: O’Shea et al. Frenotomy for tongue-tie in newborn infants. 2017.
Supporting Sucking skills-Watson Genna-2nd edition.
Biomechanics of milk extraction during breast-feeding, Elad et al 2014.
Lactasource: Frein de langue et allaitement, prise de poids du nourrisson : présentation de l'étude de Raol et al. (Pediatrics, 2026)