Tongue-tie: how to spot it and when it’s worth having it checked

The most common scene goes like this: a new mom, exhausted, her breasts sore and hurting, who has spent three weeks hearing that “it’s normal for it to hurt at first.” It isn’t normal. And one of the most overlooked causes is tongue-tie.

The second scene, years later, is the five-year-old who can’t roll their R’s, and everyone keeps saying it’ll come in time.

They’re the same problem at two different stages of life, and in both cases it’s worth getting checked. But I also want to be honest from the start: tongue-tie is overdiagnosed.

What it is, exactly

We all have a thin membrane under the tongue that connects it to the floor of the mouth. It’s called the lingual frenulum, and its job is to anchor the tongue. When that membrane is shorter, thicker or attached farther forward than usual, the tongue loses mobility.

The key word there is mobility, not appearance. A frenulum can look short and work perfectly, and another can look unremarkable and truly be limiting. That’s why an evaluation is never a photo: it’s seeing what that tongue can and can’t do.

Signs in a breastfeeding baby

In the first few months, the problem doesn’t show up in the baby’s mouth but in breastfeeding. This is what makes me suspicious:

• Ongoing pain while breastfeeding, or cracked nipples that don’t get better even after fixing the position.
• The baby keeps latching on and coming off, or makes a clicking sound while sucking.
• Very long feedings that end with the baby tired and still hungry.
• Poor weight gain even though the baby is feeding all the time.
• The tongue can’t reach past the lower gum, or the tip looks heart-shaped when the baby cries.

One important caveat: none of these signs confirms anything on its own. Breastfeeding pain has many causes, and most of them aren’t the frenulum. What points the way is when several of them show up together and don’t improve after correcting the technique with a lactation consultant.

Signs in an older child

If breastfeeding went well, the issue can resurface later. In kids three and older, what you see is trouble lifting the tongue to the roof of the mouth, difficulty licking an ice cream cone or sweeping their teeth clean with the tongue, and certain sounds that never quite come out.

I want to add some nuance about speech, because that’s where there’s the most confusion. Most pronunciation problems in children are not caused by the frenulum: they’re part of normal development and resolve on their own or with speech therapy. The frenulum becomes a suspect when it specifically affects sounds that need the tip of the tongue to touch the roof of the mouth, and when there’s also a visible mechanical limitation.

Why I say it’s overdiagnosed

In recent years the topic became popular, and the pendulum swung too far. Today I see babies who were sent for surgery without anyone evaluating their breastfeeding, and children who had surgery for a pronunciation problem that was simply their age.

A short frenulum that isn’t causing any problems doesn’t need treatment. The finding alone isn’t a reason to treat; the finding plus a functional limitation is.

How to evaluate it properly

A good assessment looks at three things: what the frenulum looks like, how much the tongue really moves, and which function isn’t working. In babies, that ideally means watching a feeding. In older kids, it means listening to them talk and asking them to make specific movements.

That leads to three possible answers: there’s nothing to do, the function needs work first, or it’s best to release the frenulum. If the answer is the third one, the procedure is simple, and I explain it in detail in the article on frenectomy.

What I don’t recommend is deciding based on a single two-second look, in either direction.