Interventional Procedures Consultation Document - Division of ankyloglossia (tongue-tie) for babies with difficulty breastfeeding


Interventional Procedure Consultation Document

Division of ankyloglossia (tongue-tie) for breastfeeding

The National Institute for Health and Clinical Excellence is examining division of ankyloglossia (tongue-tie) for breastfeeding and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure.The Advisory Committee has made provisional recommendations about division of ankyloglossia (tongue-tie) for breastfeeding.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

  • comments on the preliminary recommendations
  • the identification of factual inaccuracies
  • additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

  • The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  • The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (

Closing date for comments: 26 July 2005
Target date for publication of guidance: November 2005

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

1 Provisional recommendations

Current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance.

1.2 Division of ankyloglossia (tongue-tie) for breastfeeding should only be performed by properly trained and registered healthcare professionals.

Publication of further controlled trials on the effect of the procedure on successful long-term breastfeeding will be useful.

2 The procedure
2.1 Indications
2.1.1 Ankyloglossia, also known as tongue-tie, is a congenital anomaly characterised by an abnormally short lingual frenulum, which may restrict mobility of the tongue. It varies in degree, from a mild form in which the tongue is bound only by a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise, such as problems with latching (getting the mother and baby appropriately positioned to breastfeed successfully), sore nipples and poor infant weight gain.

Many tongue-ties are asymptomatic and some resolve spontaneously over time. If the condition is associated with problems in breastfeeding, conservative treatment includes breastfeeding advice and counselling, massaging the frenulum and exercising the tongue. However, some practitioners believe that if a baby with tongue-tie has difficulty breastfeeding, surgical division of the lingual frenulum should be carried out as early as possible. This may enable the mother to continue to breastfeed, rather than having to feed artificially.

2.2 Outline of the procedure

In early infancy, division of the tongue-tie is usually performed without anaesthesia, although local anaesthetic is sometimes used. The baby's head is stabilised and sharp, blunt-ended scissors are used to divide the lingual frenulum. There should be little or no blood loss and feeding may be resumed immediately. In an older infant or child, general anaesthesia is usually required.

2.3 Efficacy

One randomised controlled trial compared division of tongue-tie with 48 hours of intensive support from a lactation consultant. Mothers reported that 95% (19/20) of babies had improved breastfeeding 48 hours after tongue-tie division, compared with 5% (1/20) of babies in the control group (p < 0.001).

2.3.2 In one case series of 215 babies, 80% (173/215) of mothers reported improved breastfeeding 24 hours after the procedure. In another case series of 123 babies, 100% (70/70) of mothers reported improved latch after the procedure, and the 53 mothers with nipple pain noted significant improvement immediately after the procedure. In a third case series, 100% (36/36) of babies were reported to have normal tongue motion at 3 months. For more details, refer to the sources of evidence (see Appendix).

Some of the Specialist Advisors stated that it is difficult to ascertain whether any perceived improvement in breastfeeding is due to division of the tongue-tie.


2.4 Safety

Few adverse effects were reported. One case series reported that, after the procedure, 2% (4/215) of babies had an ulcer under the tongue for more than 48 hours. Two studies, including a total of 159 babies, stated that there were no complications.

2.4.2 Two studies reported that 8% (3/36) and 18% (39/215) of babies slept through the procedure. For more details, refer to the sources of evidence (see Appendix).
2.4.3 The Specialist Advisors listed bleeding, infection, ulceration, pain, damage to the tongue and submandibular ducts and recurrence of the tongue-tie as potential adverse effects. but several Advisors stated that these were likely to be very rare events.
2.5 Other comments
2.5.1 The Committee recognises that breastfeeding is a complex interaction between mother and child, and that many factors can affect the ability to feed.

Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
July 2005

Appendix: Sources of evidence

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

  • Interventional procedure overview of division of ankyloglossia (tongue-tie) for breastfeeding, February 2005

Available from:

This page was last updated: 04 February 2011