Few topics in infant feeding create more debate than tongue tie. Some families are told their baby needs a release within minutes of a visit. Others are told ties don't really matter. Both extremes miss something important: tongue function depends on far more than the frenulum.
What the tongue needs to do
During breastfeeding, the tongue has several jobs at once. It cups and stabilizes the breast, creates a seal with the lips and palate, moves in a wave to help draw milk out, and coordinates with the swallow and the breath. To do that well, it needs:
Range: enough lift, extension, and lateral movement
Strength and endurance: to keep working for a full feed
Coordination: with the jaw, lips, palate, and swallow
A stable base: from the jaw, hyoid, neck, and trunk
A frenulum can restrict range. But a tongue can also be limited by jaw tension, a high palate, low tone, a neck that's held in extension, or a baby who is too disorganized to use the skills they have.
Look at function, not only anatomy
Two babies can have frenulums that look nearly identical. One feeds comfortably. The other clicks, chomps, and leaves the parent in pain. The difference is often everything around the tongue.
A functional oral motor assessment asks:
How does the tongue move at rest, during non-nutritive sucking, and at the breast?
Can the baby lift and extend the tongue without the jaw doing the work?
How wide can the baby open, and does it change with head position?
What happens to the suck pattern as the feed goes on?
What compensations is the baby using?
Where release fits
For some babies, a release is an important part of care. When it's the right call, outcomes tend to be better when the baby's body is prepared beforehand and supported afterward. That might include addressing neck and jaw tension, building oral motor skills, and helping the baby learn to use their new range.
A release changes anatomy. It doesn't automatically change the movement patterns a baby has built around that anatomy. That retraining is where PTs, OTs, and IBCLCs working together make a real difference.
A wider lens
When a feeding problem gets labeled "tongue tie," it can stop everyone from looking further. Keeping the question open (what else is limiting this tongue?) leads to better decisions about whether to refer for release, and better recovery when release happens.
In Functional Lactation, oral motor work is always connected to the rest of the body, because the tongue can only move as well as its foundation allows.
Dr. Emily Spaeth, PT, DPT, IBCLC, is the founder of Be Well Baby® in Portland, Oregon, and teaches in Pacific University's Doctor of Physical Therapy program. If you're a PT, OT, or IBCLC who wants to work this way, join the waitlist for the Functional Lactation Intensive.
