Tongue tie is a commonly discussed topic among new parents, particularly when breastfeeding challenges arise. But not every visible frenulum is a tongue tie, and not every feeding difficulty is caused by one.
Understanding the difference between normal anatomy and a restriction that affects feeding can help families make informed decisions about their baby's care.
What is a tongue tie?
First, it is important to understand that everyone has a structure underneath their tongue called the lingual frenulum. This is a normal fold of tissue connecting the underside of the tongue to the floor of the mouth.
The presence of a lingual frenulum does not automatically mean someone has a tongue tie.
A tongue tie, medically known as ankyloglossia, occurs when the lingual frenulum restricts the tongue's range of motion. In newborns, this restriction can sometimes interfere with the tongue movements necessary for effective breastfeeding.
Lingual frenula naturally vary in appearance, thickness, and attachment location. Some are more prominent or visible than others, but these differences do not necessarily indicate a problem.
According to the American Academy of Pediatrics (AAP), Pediatrics, 2024, ankyloglossia cannot be diagnosed based on appearance alone.
The important distinction is not simply what the frenulum looks like, but whether it restricts normal tongue movement and affects feeding.
What are common signs of tongue tie in newborns?
A restrictive lingual frenulum may contribute to breastfeeding difficulties, but it is important to note that the symptoms associated with tongue tie can have other underlying causes.
Potential signs include:
Difficulty maintaining a latch: A baby may struggle to stay attached to the breast or repeatedly lose suction.
Persistent nipple pain or trauma: Breastfeeding may remain painful despite adjustments to positioning and latch.
Ineffective milk transfer: A baby may have difficulty removing adequate amounts of milk during breastfeeding.
Poor weight gain: In some cases, ineffective feeding may contribute to inadequate weight gain.
Restricted tongue movement or impaired sucking function: During a feeding and oral assessment, a baby may demonstrate limitations in tongue elevation, extension, or lateralization, difficulty cupping the tongue or maintaining suction, or poorly coordinated tongue movements during sucking.
Importantly, none of these signs independently confirms a tongue tie.
Nipple pain, latch difficulties, and poor milk transfer can have many causes totally unrelated to the lingual frenulum.
This is why tongue function matters more than appearance alone.
The Academy of Breastfeeding Medicine's 2021 position statement, published in Breastfeeding Medicine, emphasizes the importance of a thorough breastfeeding assessment, including observing feeding and evaluating milk transfer, rather than relying solely on an oral examination.
How is tongue tie evaluated?
A comprehensive evaluation considers both the baby's oral anatomy and how feeding is actually going.
This may include assessing tongue mobility, observing a breastfeeding session, evaluating latch and milk transfer, reviewing infant weight gain, and discussing any nipple pain or feeding concerns.
An IBCLC cannot independently provide a medical diagnosis of tongue tie based on the IBCLC credential alone. However, an IBCLC can assess oral function, identify feeding difficulties, and recognize signs that may warrant further evaluation.
When a restrictive lingual frenulum is suspected, families may be referred to an appropriately trained medical or dental professional for diagnosis and discussion of treatment options.
The AAP's 2024 clinical report defines symptomatic ankyloglossia as a restrictive lingual frenulum associated with breastfeeding difficulties that do not improve with lactation support.
Does every tongue tie need to be released?
No. A visible frenulum, or even an anatomical restriction, does not automatically mean surgical treatment is necessary.
For babies who are feeding effectively, intervention is generally not indicated.
When significant breastfeeding difficulties persist despite appropriate lactation support, a frenotomy (a procedure to release the frenulum) may be considered following a comprehensive evaluation and discussion of potential benefits, risks, and alternatives.
A Cochrane systematic review published in 2017 found that frenotomy may reduce maternal nipple pain in the short term, but evidence for consistent improvements in infant feeding and longer-term breastfeeding outcomes remains limited.
In my practice, I take a conservative approach to tongue tie concerns. A frenotomy is a surgical procedure, and the decision to pursue one deserves careful consideration. It involves recovery and follow-up care and can be stressful for families. My priority is to thoroughly assess feeding function and explore appropriate, nonsurgical interventions before recommending further evaluation for a possible release.
This approach is consistent with the AAP's recommendations to reserve frenotomy for significant functional impairment when nonsurgical interventions have been unsuccessful.
The goal is not to treat the appearance of a frenulum. It is to address feeding difficulties using an individualized, evidence-based approach.
Getting breastfeeding support
If you're experiencing painful breastfeeding, latch difficulties, or concerns about milk transfer, a comprehensive feeding assessment is an important first step.
At R&R Motherhood, I provide individualized lactation support for families in Arlington, Lexington, and the Greater Boston area, helping identify potential causes of feeding challenges and develop an appropriate plan for your family.
