Tongue-tie is more than a just a metaphor for stumbling over your words. It’s an actual oral condition that can impact many things from breastfeeding to your airway, from speech to dental health.

Still, the research about tongue-tie is evolving, and there’s a lot that’s misunderstood. If your child has been diagnosed with tongue-tie, here’s what you need to know in order to figure out next steps.

Oral issues like tongue and lip ties develop in the womb as a result of a gene mutation passed on as a dominant trait.

A baby born with a tongue-tie, or ankyloglossia, will have an overly short or thick frenulum that restricts the tongue’s movement. The frenulum is a small band of tissue that extends from the floor of the mouth to the bottom of the tongue.

Tongue-ties are often classified in different ways. Some healthcare providers will classify a tongue-tie according to the Coryllos I–IV classification system, for example, type I, type II, type III, and type IV.

Unlike the numerical classification system that labels the degree of severity for cancer, these numerical classifications do not necessarily guide diagnosis or treatment. Instead, they are used for descriptive purposes to explain where the tie attaches to the tongue.

Other healthcare professionals will classify a tongue-tie only as “anterior” or “posterior,” while still others use the Hazelbaker assessment tool for lingual frenulum function (HATLFF) to assess tongue function.

The HATLFF is the only widely used assessment tool that assesses tongue function. The majority of lactation professionals use the HATLFF to determine whether a baby might be a candidate for surgical intervention (and then refer to a specialist accordingly).

While the exact prevalence of tongue-tie is unknown, current evidence suggests a 3 percent to 5 percent occurrence, with a range of 0.1 percent to 10 percent, depending on the criteria used to evaluate the frenulum. Some healthcare providers have given anecdotal estimates of up to 25 percent prevalence.

Bobby Ghaheri, MD, an otolaryngologist, says it’s very important to distinguish that the 3 to 5 percent prevalence is only accounting for obvious or visible anterior tongue-tie.

“The reason we’re hearing about tongue-tie more now is that research in the last 10 to 11 years has demonstrated that the part of the tongue responsible for suction is the middle of the tongue, not the tip,” says Ghaheri.

This newer research refers to the part of the tongue restricted by a posterior tongue-tie, which Ghaheri says is a bit of a misnomer since the tie is still under the front of the tongue but less visible.

But this change, which includes identifying when the frenulum attaches to the middle of the tongue as well as to the tip, could be one of the reasons we see some research going as high as 10 percent prevalence.

Your child’s pediatrician or primary care doctor can diagnose a tongue-tie. However, Andrea Tran, RN, MA, IBCLC, says a lactation consultant may be the first person to notice a tongue-tie when evaluating for breastfeeding issues.

Tran says some of the more common signs and symptoms of a tongue-tie include nipple pain and trauma in the mother, as well as infant issues such as trouble staying latched, clicks when breastfeeding, and poor milk transfer, which can lead to issues with weight gain and milk supply.

In those cases, Tran refers mother and baby to their doctor for further evaluation. If their doctor is not trained in identifying tongue-ties, or they have concerns about a diagnosis, Tran will recommend the parent have their baby evaluated by an ear, nose, and throat doctor (ENT or otolaryngologist), or pediatric dentist.

The goal of the evaluation, says Ghaheri, is to determine the degree of tension in the frenula of the lip and tongue on the surrounding tissue.

A thorough evaluation of a tongue-tie — especially when determining whether to intervene surgically — should include assessing tongue function, particularly during feeding, in addition to assessing the tension of the tissues.

The decision to treat a tongue-tie often comes down to the severity. Some care providers will take a wait-and-see approach for very mild cases, while others will recommend a frenotomy (also called frenectomy), which is the procedure used to release the lingual frenulum.

“Frenotomies are simple, usually take just a few minutes to perform, and can be done in a doctor’s office,” says Jessica Madden, MD, and medical director at Aeroflow Breastpumps. The most common side effect is a mild amount of bleeding.

While a frenotomy is usually a fairly simple procedure, parents or caregivers have to physically stretch the tissue that’s been cut or lasered every day for at least 3 to 4 weeks afterward. This prevents the tissue from regrowing too tightly during the healing process.

The stretches are not complicated, but most babies don’t like them, and it can be difficult for parents.

This procedure is often a choice for parents who are experiencing issues related to breastfeeding their infant.

A 2016 study found that surgical release of tongue or lip tie, and more specifically, posterior tongue-tie, resulted in improvements in maternal and infant breastfeeding outcomes. Additionally, researchers discovered that the improvements occurred early, at 1 week post-procedure, and continued to improve for several weeks.

Ghaheri says tongue-tie treatment depends on the severity, age, and symptoms. “There are surgical release techniques of simple snipping the front band — that’s the most common, but many feel that it’s inadequate because it does not release the posterior tongue-tie,” he says.

Ghaheri prefers not to snip with scissors, but to use a laser, which typically results in less bleeding. He also stresses the importance of symptomatic support, such as lactation consultants, speech pathologists, and occupational therapists: “It’s always a team effort.”

Treating difficulties with breastfeeding in infants with frenotomy is a controversial topic. Although the procedure is relatively low risk, some people question the need to remove a tongue-tie to help with feeding.

Complications from the procedure could include bleeding, infection, damage to tongue or salivary glands, or — if the stretches aren’t performed afterwards — regrowth of the tight tongue-tie.

Ultimately, the decision to release a tongue-tie should be between a doctor and patient, or in this case, a doctor and the patient’s parent. This will allow parents to make the best decision for their unique circumstances.

If a frenotomy is not recommended, Madden says other ways to manage tongue-ties include craniosacral therapy, lactation interventions, physical and occupational therapy, and oral motor therapy.

Tongue-ties can have an impact on nursing, say all three experts. “Tongue-tie prevents an open mouth seal, and if there’s no seal, then there’s no suction,” explains Ghaheri. In those instances, he says the baby uses their lips and gums to hold on, which starts the cascade of various symptoms.

Madden says it is well documented that tongue-ties can cause pain with breastfeeding. Tongue-ties can also interfere with latching, she says, due to the tongue not being able to extend and elevate to effectively latch onto the nipple and remove milk.

“Both pain and an ineffective latch can lead to a decrease in milk supply, aerophagia (swallowing too much air), and failure to thrive or poor weight gain,” says Madden. That said, she does point out that we desperately need more research regarding the effects of tongue-ties on babies.

We know that tongue-tie can contribute to weight gain problems and failure to thrive in infancy. But the potential problems with an untreated tongue-tie don’t end when your baby stops feeding at the breast.

Other than feeding issues, tongue-tie can also cause problems with dental occlusion (misalignment) and orthodontic health. But again, Ghaheri says the evidence is still emerging.

Speech articulation and oral biomechanics may also be impacted by tongue-tie, according to Stanford Children’s Health. Although the ability to learn speech is not a problem, an untreated tongue-tie may cause issues with the way a child pronounces words.

Some families choose not to treat a tongue-tie because they’ve been advised that it will stretch over time. While many providers stand by this claim, there is an emerging body of research that says the frenulum itself consists of a high amount of collagen cells that don’t stretch.

Still, in some cases, there are no long-term effects of leaving a tongue-tie. As a child grows, their oral functioning can compensate for the restricted movement of the tongue.

Lip and buccal (cheek) ties are two other oral ties you may find in babies. Similar to a tongue-tie, an upper lip tie or superior labial frenulum is the soft tissue that attaches the upper lip to the anterior gums.

All newborns have some degree of an upper lip attachment, but problems with feeding may occur if the upper lips aren’t able to move because the lip tie is so tight or rigid. An untreated lip tie can also potentially lead to tooth decay and other dental problems once a child’s teeth start coming in.

While rare, some babies may also have a buccal tie, which is an abnormal tie extending from the cheeks to the gums.

Although many studies support treating anterior tongue-ties to alleviate breastfeeding issues, upper lip ties are still being studied for more evidence-based recommendations related to diagnosis and treatment.

Releasing a tongue-tie is a safe and simple procedure that may help with breastfeeding problems.

If you’re experiencing issues with breastfeeding or think your baby has a tongue-tie, contact your doctor, midwife, or lactation consultant. They will be able to perform an evaluation and refer you for treatment.