Nursing a newborn is a tricky dance for everyone involved. Your baby is new to the world, and was — until very recently — living in a dark, cozy, cave of liquid. In other words, everything is brand new to them, including figuring out how to eat. You, likewise, may be brand new at this whole breastfeeding thing and hopefully, you’ve got people around you who can help you figure it out. It’s normal to struggle a bit at first, but if you’re having nipple pain, or it seems like your newborn isn’t transferring enough milk, you may find yourself hearing the phrase “tongue tie.” Whether you hear it from a lactation consultant, your pediatrician, or see it pop up in a text thread with other new parents, the topic of tongue ties in babies can be a surprisingly confusing one.
What is a tongue tie in babies?
If you’ve been doing some classic new-parent late-night Googling and decided that your breastfeeding battles could be chalked up to a newborn tongue tie, you may want to hit pause — at least for a moment — and learn a bit more about what exactly a tongue tie is, and what (if anything) needs to be done about it if your baby does indeed have one.
The medical term for tongue tie is Ankyloglossia. “‘Ankylo’ means ‘to tether and ‘glossia’ just means tongue. So ‘tethered tongue,’ that's what Ankyloglossia is,” explains Dr. Anna H. Messner, M.D., Division Chief of Head & Neck Surgery at Texas Children’s Hospital. “It is a condition of limited tongue mobility caused by a restrictive lingual frenulum.”
Everybody has a lingual frenulum, Messner clarifies. It is simply the tissue that connects your tongue to your mouth. Historically, the definition of ‘tongue tie’ was having a lingual frenulum that attached all the way to the very tip of the tongue, meaning the tongue tip would be fully tethered down to the jawbone. But in recent years, the definition seems to have become much broader. In fact, a very recent paper in the journal Pediatric Gastroenterology, Hepatology and Nutrition explores the fact that there really is no, single agreed-upon definition of a tongue tie right now, despite that fact that data shows a tenfold (and likely higher) increase in diagnoses and corrections in the U.S.
How do you know if a baby is tongue tied? Signs doctors look for
Despite the rather muddy definition and controversy surrounding the diagnosis of mild tongue ties within the medical community, Messner says that severe tongue ties are quite obvious. So, what does a tongue tie look like? “When a baby’s tongue is elevated, is the tip rounded or does it have a notch? Or if they start to stick their tongue out, does it look more like a heart?” asks Messner, saying that this heart-shaped tongue is a classic sign that your baby has a tongue tie. Though there is debate within the medical community about exact numbers and the quality of data available, the American Academy of Pediatrics suggests that about 10% of the population have “some form of tongue tie.”
According to Messner, a few tell-tale ankyloglossia symptoms in infants that your doctor will consider in making a diagnosis include:
- The shape of your baby’s tongue. Your family’s health care provider will look for that tell-tale heart shape, and any other signs of restriction.
- Where does your baby’s tongue attach to their mouth? To assess its existence and severity, your doctor will look to see if it attaches to the jaw at the top where the teeth will eventually come in, at the bottom of the bone, or to the floor of the mouth.
- How they can lift it. “When a baby cries, they will automatically try to lift their tongue. Some babies can lift it fully, some just a little bit on the sides, and some really have trouble lifting it at all,” she says.
- How your baby can protrude it. “Sometimes it's hard to get babies to [stick their tongue out], but you can sometimes see them trying,” Messner explains. Seeing if your baby can stick out their tongue is a valuable piece of information in making a diagnosis and decision about possible treatment.
Breastfeeding parents may also experience symptoms that indicate that their baby is tongue tied, and in fact many people find out about anklyoglossia because of an intial struggle with nipple pain or a bad latch in the first days of nursing. “The symptoms that have been shown, through research, to really be affected by tongue tie are the ability of the baby to latch onto the breast, or the baby can latch but mom has quite a bit of nipple pain,” Messner explains. However, because a bit of nipple discomfort is normal at the start of breastfeeding, it can be hard to initially tell what’s causing it. “Is this the normal adjustment of getting used to breastfeeding? the baby, getting used to mom, and mom getting used to the baby? Or is it a poor latch due to tongue tied?” Just to complicate matters further, she says that not every baby who is tongue-tied has trouble breastfeeding. But, there are a significant number of babies that don't have a great latch, which affects the breastfeeding.
How serious is tongue-tie in babies? Causes and potential risks
How serious it is if you find out that you have a tongue tied newborn? And, most importantly, how would a parent know when it's time to seek treatment? This is where it can get tricky. If baby is struggling to feed or transfer, that can be urgent, and your pediatrician will follow the baby’s weight gain, Messner says. And nipple pain or damage caused by poor latch — which can be potentially related to tongue tie — is also an urgent issue.
If your child is older, and you’re exploring tongue tie diagnosis or correction for a developmental reason — perhaps a speech therapist recommended it — the severity of the tongue tie is again a key factor in deciding what approach is appropriate. “Tongue tie is so varied. You can have a really minor tongue tie where there is a slightly limited range but doesn't necessarily have a big impact, or it can be an incredibly significant tongue tie where there is a big impact to things like breastfeeding or being able to get your articulators to where they need to be in your tongue,” explains Greta West, a neurodivergent speech language pathologist licensed in Oregon and California.
Both West and Messner agree that it’s important to have your baby evaluated by a trusted health care provider, and maybe even seek a second opinion if you’re concerned about a tongue tie.
Tongue tie surgery: Is treatment necessary?
Increasingly, many studies — like this 2021 study from the Ear, Nose and Throat Journal focused on tongue tie corrections and speech articulation — assert that it’s possible that tongue tie corrections (frenotomies) are being over-done in the U.S., and Messner strongly agrees with that.
“Doing frenotomy [in-office tongue tie clip] is a very safe procedure, which is part of the reason it's overdone right now,” Messner says.
Are there any risks or disadvantages to clipping a tongue-tie?
While tongue tie corrections are generally quick procedures done in your pediatrician’s office, they do still have some associate risks, like bleeding and scar tissue. “For any procedure, there are potential disadvantages and there are potential risks,” Messner explains, saying that the actual physical risks of frenotomy are bleeding and postoperative pain.
However, there is another risk that many don’t consider, she adds, and that is that focusing on tongue tie as the cause of nursing or feeding difficulties may mask other issues. She urges parents simply to keep in mind that there may be other breastfeeding-related challenges. “The positioning of the baby is the most common reason that women have difficulty with breastfeeding,” she explains. “Sometimes people will even miss problems in the baby. So there are babies who don't feed well because they have other medical problems.”
A 2019 study in the journal JAMA Otolaryngology—Head & Neck Surgery calls out one surprising potential harm caused by what many pediatricians like Messner consider to be the recent trend towards over-diagnosis of tongue tie and corrections: “A serious risk of frenotomy is the out-of-pocket expense for the family. Unfortunately, there is much variation related to clinicians performing a frenotomy, with dental professionals, pediatric otolaryngologists, and neonatologists providing this service with often-unpredictable cost and coverage by medical insurance.”
While a tongue tie correction for your baby may be helpful in your breastfeeding experience, it also may not be necessary. A first step towards getting everyone on solid ground with any breastfeeding struggles, or even speech delays in older toddlers, is talking with your family’s pediatrician about what your concerns are.
Messner, A., (2000) Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, https://pubmed.ncbi.nlm.nih.gov/10967382/
Borowitz, S.M., (2023) What is tongue-tie and does it interfere with breast-feeding? – a brief review. Pediatric Gastroenterology, Hepatology and Nutrition https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10167863/
Melong, J., Bezuhly, M., Hong, P., (2021) The Effect of Tongue-Tie Release on Speech Articulation and Intelligibility. Ear, Nose & Throat Journal https://journals.sagepub.com/doi/10.1177/01455613211064045
Walsh J, Links A, Boss E, Tunkel D. (2017) Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngology–Head and Neck Surgery https://journals.sagepub.com/doi/10.1177/0194599817690135
Dr. Anna H. Messner, MD, FACS, FAAP, Division Chief, Otolaryngology/Head & Neck Surgery at Texas Children's Hospital
Greta West, a neurodivergent Speech Language Pathologist