Tongue Ties, Revisited: Why Careful Assessment Still Matters

Tongue ties are everywhere right now. Social media is saturated with photos of frenulums circled in red, before-and-after videos, and confident claims about what must be done. But feeding is not a photo — it’s a relationship between two people. And evidence-based care moves far more slowly (and carefully) than online trends.

As a lactation consultant, my role is not to diagnose a tongue tie in isolation, but to assess how a baby and parent function together as a dyad, and to help families make informed decisions rooted in outcomes, not algorithms.

A Brief Historical Perspective

Tongue tie (ankyloglossia) is not a new diagnosis. It has been described in medical literature for centuries, with periods of both over-treatment and dismissal. In the mid-20th century, routine frenotomies fell out of favor due to lack of clear evidence. More recently, increased breastfeeding support and awareness of oral function have brought tongue ties back into focus — sometimes appropriately, sometimes excessively.¹

History reminds us of something important: the pendulum swings, but science advances slowly. Careful assessment has always mattered.

Visual vs Functional Assessment: Why Appearance Alone Isn’t Enough

Not every visible frenulum is a tongue tie — and not every tongue tie looks dramatic.

Research consistently shows that appearance alone does not reliably predict feeding outcomes.² Some babies with restrictive frenulums feed efficiently and comfortably. Others with minimal visual restriction struggle significantly.

That’s why functional assessment matters:

• Can the baby transfer milk effectively?

• Is feeding comfortable for the parent?

• Is weight gain appropriate?

• Are there signs of compensatory behaviors?

Tongue tie is a functional diagnosis, not a visual one.

Outcomes-Based Care: The Question Isn’t “Is There a Tie?”

The more meaningful clinical question is:Is this dyad experiencing a feeding problem that is not improving with skilled lactation support?

Outcomes-based care focuses on:

• Milk transfer

• Infant growth

• Maternal comfort

• Feeding efficiency

• Sustainability of the feeding plan

If feeding is effective, comfortable, and meeting goals — intervention may not be necessary, even if a frenulum looks restrictive.³

Working as a Dyad

Babies do not feed in isolation. A latch that works beautifully for one parent may not work for another. Breast anatomy, milk flow, positioning, infant tone, and birth history all interact.

Supporting the dyad may include:

• Positioning adjustments

• Latch optimization

• Managing oversupply or slow flow

• Oral motor support

• Time and maturation

Sometimes these changes alone resolve symptoms — sometimes they clarify whether additional intervention is needed.

When to Refer — and When to Monitor

Referral is appropriate when:

• Pain persists despite skilled lactation support

• Milk transfer remains poor

• Weight gain is inadequate

• Feeding is inefficient or exhausting

• Compensatory patterns persist

Monitoring may be appropriate when:

• Feeding is improving

• Weight gain is adequate

• Pain is resolving

• The family feels supported and confident

There is no single timeline that fits every baby. Individualized care matters.

Addressing Tongue Ties: More Than One Path

When intervention is appropriate, options may include:

• Continued lactation support

• Bodywork or oral motor therapy

• Frenotomy or frenectomy (performed by trained medical providers)

• Post-procedure feeding support and reassessment

Surgery is not a standalone solution. Evidence shows outcomes are best when procedures are paired with comprehensive feeding support before and after.⁴

Finding Experienced Support Matters

Tongue tie care is nuanced. Families benefit most from providers who:

• Use functional assessment tools

• Collaborate across disciplines

• Avoid one-size-fits-all recommendations

• Track outcomes over time

Social media is not research. And confident messaging is not the same as evidence-based care.

When to Seek Help

If feeding feels painful, stressful, or unsustainable — trust that instinct. Early, skilled assessment can prevent prolonged struggles and unnecessary interventions.

Careful assessment matters. Science evolves slowly. And every frenulum deserves context.

References (AMA Style)

1. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2–3):123-131.

2. Amir LH, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. Int Breastfeed J. 2006;1:3.

3. Academy of Breastfeeding Medicine. ABM Clinical Protocol #11: Guidelines for the Evaluation and Management of Neonatal Ankyloglossia. Breastfeed Med. 2021;16(5):351-356.

4. Walsh J, Tunkel D. Diagnosis and treatment of ankyloglossia in newborns and infants: A review. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1032-1039.