A frenulum is not a tongue tie.
The misunderstanding surrounding tongue ties and frenula often creates confusion for parents. Tongue ties can profoundly affect feeding, speech, sleep, and craniofacial development. Without clarity, infants and children may not receive the timely care they need to thrive.
As a Lactation and Weaning Specialist and Jamaica’s first and only Paediatric Craniosacral Therapist, with specialised training in tongue ties, I have worked closely with families and healthcare professionals to address these challenges. This guide provides parents with a clear understanding of tongue ties, their impact, and the importance of functional and holistic care.
What Is a Tongue Tie?
A tongue tie, or ankyloglossia, is a condition where the lingual frenulum—the tissue connecting the underside of the tongue to the floor of the mouth—is unusually tight, thick, or short. This restriction limits the tongue’s movement, often leading to a range of functional challenges.
It is crucial to understand that having a frenulum is normal; everyone has one. However, not all frenula cause restrictions. The key to diagnosing a tongue tie lies in evaluating how the tongue functions, not just its appearance. A visible frenulum alone does not equal a tongue tie.
The guiding question is always: How does the tongue move and function?
The Formation and Classification of Frenula
During early embryonic development, the tongue is initially fused to the floor of the mouth. Over time, the tissue beneath the tongue thins and recedes, leaving behind the frenulum. The thickness, length, and placement of the frenulum vary from person to person.
Classification of Tongue Ties
Classification systems, such as Kotlow’s, categorise tongue ties based on the attachment points of the frenulum:
Type 1: Attaches at or near the tip of the tongue.
Type 2: Attaches a few millimetres behind the tip.
Type 3: Attaches mid-tongue.
Type 4: Lies beneath the mucosa on the floor of the mouth (posterior tie).
These classifications describe appearance but are not a measure of severity. For instance, a barely visible Type 4 tie can severely restrict function, while a visible Type 1 tie may not affect functionality at all.
The focus must always be on functionality rather than appearance.
Symptoms and Lifelong Impacts
In Infants
The first signs of a tongue tie often emerge during breastfeeding. Breastfeeding requires precise coordination of the tongue, lips, jaw, and soft palate, and any restriction in tongue movement can create significant challenges:
Difficulty latching, leading to frustration for both baby and mother.
Nipple pain or trauma, such as soreness, cracking, or bleeding.
Poor milk transfer, leading to low weight gain or failure to thrive.
Prolonged or frequent feeding sessions without satisfaction.
Clicking or popping sounds during feeding, indicating poor suction.
Sucking blisters on the lips from compensatory lip gripping.
Gassiness or reflux due to air intake during feeding.
While these issues are commonly observed during breastfeeding, they can also arise during bottle feeding. Babies with tongue ties may struggle to maintain a proper seal on the bottle nipple, leading to similar problems such as excessive air intake, inefficient feeding, and prolonged feeding sessions.
In Toddlers and Young Children
As children grow, untreated tongue ties can lead to challenges such as:
Speech delays or difficulty pronouncing sounds requiring tongue elevation or movement (e.g., “r,” “l,” “th,” “s”).
Difficulty chewing or swallowing, leading to picky eating or choking.
Persistent dental issues like a high, narrow palate or crowded teeth.
Sleep problems, such as snoring, mouth breathing, or sleep apnea.
Oral aversion to certain textures or foods.
In Teens and Adults
Lingual restrictions can cause lifelong challenges, including:
Speech difficulties or lack of confidence in social settings.
Airway issues like obstructive sleep apnea.
Chronic neck, jaw, or shoulder tension.
Dental and orthodontic complications from poor tongue posture.
TMJ (temporomandibular joint) disorders.
What Does a Functional Assessment Involve?
Understanding the full impact of a tongue tie involves both a clinical diagnosis by providers such as a paediatrician, dentist or ENT, and a detailed functional assessment. My role focuses on evaluating how tongue function affects feeding, oral development, and body alignment to complement the diagnostic process.
As a Lactation and Weaning Specialist and Paediatric Craniosacral Therapist, I can perform many aspects of a functional assessment.
1. Oral Function Assessment
Evaluating oral function involves examining the tongue’s mobility and coordination in detail. This requires looking under the tongue to assess:
Elevation: Can the tongue lift to the roof of the mouth, both at rest and during movement?
Extension: Can the tongue extend past the lower lip without compensation from the jaw or lips?
Lateralisation: Can the tongue move side-to-side smoothly and with control?
Suction and mobility: Can the tongue create adequate suction for effective feeding, such as during breastfeeding or bottle feeding, and does it move fluidly without tension or restriction?
By assessing these movements, I can opine on whether the tongue is functioning optimally or if restrictions are present.
2. Breastfeeding Evaluation (for Infants)
Breastfeeding provides real-time insight into tongue function. A skilled lactation professional with experience in tongue ties will:
Observe how the baby latches onto the breast.
Evaluate the suck-swallow-breathe coordination.
Assess milk transfer, feeding efficiency, and signs of compensation (e.g., lip grasping, excessive gassiness, or clicking sounds).
A poor latch or inadequate milk transfer often indicates functional restrictions in the tongue, even if the frenulum appears “normal.”
3. Feeding and Chewing Evaluation
For toddlers and older children, functional assessments include observing how they manage food during meals:
Does the child gag, choke, or avoid certain textures?
Can they manipulate food effectively in the mouth?
Do they chew on one side of the mouth or swallow food without adequate mastication?
Difficulty with these tasks may reveal tongue restrictions that interfere with proper feeding mechanics.
4. Full-Body Structural Assessment
The tongue does not function in isolation. Its movement and coordination are intricately connected to muscles and fascia throughout the entire body—from the head and neck all the way down to the toes. A comprehensive assessment considers:
Signs of Tension Throughout the Body: Tension originating from a tongue tie can extend beyond the oral cavity, affecting the neck, shoulders, back, pelvis, and even the legs and feet. This widespread tension can manifest as muscle tightness, postural imbalances, or asymmetrical movement patterns in your child.
Structural Imbalances: Conditions such as torticollis (tight neck muscles) or head tilt can affect feeding mechanics and overall development. These imbalances may cause compensatory adjustments in posture and movement that impact the entire musculoskeletal system, including the hips, knees, and ankles.
Global Fascial Connections: The fascia is a continuous web of connective tissue that envelops muscles and organs throughout the body. Restrictions in the tongue's movement can create fascial tension that influences distant areas, potentially affecting alignment and function all the way to the toes.
Depending on the findings, your child may need further evaluation by medical professionals such as an Ear, Nose and Throat Specialist (ENT) (best placed to assess potential impacts on airway health and sleep issues); a Speech-Language Pathologist (SLP) (best placed to assess potential impacts on speech development and articulation); or a paediatrician, who plays a central role in overseeing your child’s overall health and coordinating care among specialists. My assessments are designed to offer complementary insights that support and guide their diagnostic and treatment process.
Treatment Options: Where Surgery Fit
1. Functional Assessment First
A frenotomy (tongue tie release) should only be performed after a detailed evaluation by trained professionals to ensure that surgical intervention is genuinely needed and part of a broader care plan.
For infants, breastfeeding is a critical functional activity that provides insight into how the tongue and surrounding structures are working. Lactation professionals, such as Certified Lactation Counsellors (CLCs), play a vital role in assessing feeding mechanics, supporting optimal latch, and guiding parents through pre- and post-surgical care. Their expertise ensures that the infant’s ability to feed effectively is a core focus of the treatment plan.
2. Craniosacral Therapy (CST): Preparing and Supporting the Body
Craniosacral Therapy (CST) is a gentle, hands-on technique that helps release tension and restore balance in the body. It is highly effective both before and after surgery, optimising outcomes and reducing complications.
Why CST Before Surgery?
Pre-surgical CST ensures the body is fully prepared by:
Releasing tight fascia and tension: Particularly around the tongue, jaw, and neck, creating an environment where the tongue can function more freely.
Improving tongue mobility and alignment: Enhancing the tongue’s range of motion ensures a cleaner, more effective release during surgery.
Addressing compensatory patterns: These patterns, such as lip or jaw gripping during feeding, can mimic tongue tie symptoms or worsen restrictions. Resolving them helps distinguish tension from true structural ties.
Minimising the risk of reattachment: Relaxed, flexible tissues have a lower likelihood of improper healing after surgery.
Why CST After Surgery?
Post-surgical CST is equally crucial for supporting the body’s healing process:
Aiding recovery: By reducing inflammation and encouraging balanced tissue healing.
Releasing residual tension: While surgery addresses structural restrictions, tension in surrounding tissues may persist, limiting function. CST helps resolve these issues.
Promoting integration: The tongue must adapt to its restored mobility and reintegrate into feeding, speech, and oral posture. CST supports this process by aligning craniofacial structures and ensuring proper functional relationships.
Preventing new compensatory patterns: The body may attempt to create new workarounds as it adjusts to post-surgical changes. CST prevents these patterns from forming.
3. Surgery: The Role of Frenotomy
Frenotomy is typically recommended when a tongue tie significantly impacts feeding, speech, airway health, or craniofacial development and when other supportive interventions like bodywork have prepared the tissues. Surgical intervention, when indicated, should be performed by experienced providers.
If your child is being considered for surgery, I can provide pre- and post-surgical support through bodywork and functional therapy.
Tension and Tongue Tie Symptoms: The Mimicry Problem
To make matters more complicated, not all feeding, speech, or oral challenges stem from a structural tongue tie. Sometimes, symptoms that resemble tongue tie are caused by tension or imbalance elsewhere in the body, which can restrict tongue mobility or mimic the functional challenges associated with tongue ties. This phenomenon, known as the mimicry problem, highlights the importance of assessing the whole body, not just the frenulum, when evaluating potential tongue tie issues.
How Tension Develops
Tension can arise from various prenatal and postnatal factors, including:
In-utero Positioning. During pregnancy, babies often adopt specific positions in the womb. If a baby spends extended periods in a tightly curled position, certain muscles, including those in the neck, jaw, and tongue, can become tense or shortened. For instance, a baby with their head tilted to one side (e.g., torticollis) may have difficulty moving their tongue freely, leading to symptoms that look like a tongue tie.
Birth Trauma. The birthing process exerts significant pressure on a baby’s head and body, particularly during a long or difficult delivery. This pressure can compress the cranial bones or cause tightness in the neck, jaw, and soft tissues. Babies delivered with the assistance of tools like forceps or vacuum extraction are particularly prone to these tensions, as are those born via caesarean section, where the sudden transition can lead to fascial restrictions.
Postural and Musculoskeletal Imbalances. After birth, if a baby prefers to turn their head to one side or shows asymmetry in their posture, it can indicate underlying tightness in their neck or jaw muscles. This tension can limit the tongue's range of motion and affect feeding or speech development.
How Tension Mimics Tongue Tie Symptoms
Tension in the body can interfere with the tongue’s ability to move freely, creating symptoms commonly attributed to tongue ties:
Feeding Challenges: Babies with tight neck or jaw muscles may struggle to latch, create suction, or coordinate the suck-swallow-breathe reflex. This can lead to nipple pain, poor milk transfer, or prolonged feeding sessions.
Oral Motor Restrictions: Even without a structural tongue tie, tension in the fascia (connective tissue) surrounding the tongue and jaw can limit tongue elevation, extension, or lateralisation, mimicking the physical symptoms of a tie.
Speech Delays: Restricted tongue movement due to tension may impact speech articulation, making it difficult for children to form certain sounds.
Airway Issues: Tension in the neck and jaw can contribute to improper tongue posture (e.g., the tongue resting low in the mouth), which can lead to mouth breathing, snoring, or even sleep apnea.
Take the First Step
If you are concerned about a possible tongue tie or have questions about how it may affect your child, I’m here to help. As a trained specialist in lactation, craniosacral therapy, and tongue tie management, I work closely with families and healthcare teams to create tailored care plans that address your child’s unique needs.
If you are a healthcare provider and would like my input on tongue function or wish to refer for Craniosacral Therapy (CST) pre- and post-surgery, I am happy to collaborate to support your patients with a comprehensive, multidisciplinary approach.
Contact me today to schedule a consultation or to discuss how we can work together to ensure the best outcomes for your child or patient’s well-being.
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