The Impact of Tongue Tie on Swallowing and the Implications for Breastfeeding and Starting Solids

Effective tongue-tie assessment considers anatomy, mobility, feeding, and overall oral function.

Tongue-tie has become one of the most discussed topics in pediatric dentistry, lactation, speech-language pathology, and orofacial myofunctional therapy. Yet despite growing awareness, important questions remain about how to identify clinically significant restrictions, when intervention is necessary, and what truly improves patient outcomes.

Not every visible lingual frenulum represents a functional restriction. Not every feeding difficulty is caused by a tongue-tie. And not every patient with restricted tongue movement requires surgery.

In an Airway Circle Thursday Night Live presentation, Dr. Sharon Smart, speech-language pathologist, Senior Lecturer at Curtin University, and Senior Research Fellow at St John of God Hospital in Perth, Western Australia, shared an evidence-based perspective on tongue-tie assessment, infant feeding, swallowing function, and clinical management.

With a PhD in pediatric feeding and communication disorders, Dr. Smart's research focuses on ankyloglossia, orofacial myofunctional therapy, infant feeding, and pediatric dysphagia. Her work also contributes to the development of professional guidelines, clinical education, and multidisciplinary research initiatives.

Her message emphasized an important principle: the presence of a lingual frenulum is not, by itself, a diagnosis. What matters is whether the tissue restricts movement and interferes with function.

For myofunctional therapists, speech-language pathologists, dentists, lactation consultants, ENTs, pediatricians, and other airway-focused professionals, this conversation offers important insights into making better clinical decisions through functional assessment and interdisciplinary collaboration.

Understanding Tongue-Tie Beyond Appearance

Ankyloglossia, commonly known as tongue-tie, refers to a restrictive lingual frenulum that limits tongue mobility and may interfere with oral function.

The lingual frenulum is a normal anatomical structure found beneath the tongue. Its presence alone does not indicate pathology.

Dr. Smart emphasized that clinicians must evaluate both the appearance of the frenulum and its impact on movement and function.

A prominent frenulum may be visible without causing meaningful restriction. Conversely, a less obvious frenulum may be associated with functional limitations that become apparent during feeding or other oral motor tasks.

This is why visual inspection alone is insufficient.

A comprehensive assessment should consider whether the tongue can elevate, lateralize, protrude, and coordinate movement during activities such as sucking, swallowing, chewing, and speech.

Most importantly, the clinician must determine whether the observed restriction is contributing to the patient's actual difficulties.

How Common Is Tongue-Tie?

Tongue-tie is frequently identified in newborns and infants, but reported prevalence varies depending on the population studied and the criteria used for diagnosis.

Dr. Smart discussed a 2021 systematic review by Hill and colleagues that estimated the overall prevalence of ankyloglossia at approximately 8%.

The review also reported differences based on sex, age, and assessment method.

Reported prevalence was higher among boys than girls, with estimates of approximately 7% and 4%, respectively. Studies using standardized assessment tools identified tongue-tie more frequently than studies relying primarily on visual examination.

These differences highlight an important challenge: clinicians are not always using the same criteria to define ankyloglossia.

For healthcare professionals, this reinforces the need for consistent terminology, reliable assessment tools, and careful interpretation of clinical findings.

The goal should not be to identify as many tongue-ties as possible.

The goal should be to identify restrictions that have meaningful functional consequences.

Structure and Function Must Be Evaluated Together

Assessing tongue movement and functional performance is essential when evaluating a possible restriction.

One of the central themes of Dr. Smart's presentation was the importance of combining structural examination with functional assessment.

A visible or palpable frenulum provides anatomical information, but it does not tell clinicians how effectively the tongue functions.

A patient may demonstrate adequate protrusion while struggling with elevation or lateralization. Another patient may move the tongue well during isolated exercises but have difficulty coordinating those movements during feeding.

Dr. Smart described three essential components of comprehensive tongue-tie assessment:

1. Structural examination: Evaluating the lingual frenulum and surrounding oral anatomy.
2. Isolated oral motor assessment: Observing tongue mobility, strength, coordination, and range of movement.
3. Functional assessment: Examining how the tongue performs during feeding, swallowing, chewing, or other relevant activities.

These components should be interpreted together.

A finding that appears significant during an isolated movement task may have little effect on feeding, while a subtle restriction may become more apparent during a complex functional activity.

Clinical decision-making should be guided by the complete picture.

Why Tongue Mobility Matters for Swallowing

Swallowing is a complex process that involves coordinated activity across multiple anatomical structures.

Dr. Smart reviewed three major stages of swallowing: the oral phase, pharyngeal phase, and esophageal phase.

Tongue-tie is most directly relevant to the oral phase, particularly when restricted mobility interferes with bolus preparation or movement through the oral cavity.

The oral phase includes anticipating food, preparing it for swallowing, forming a cohesive bolus, and transporting that bolus toward the pharynx.

The tongue plays a central role in each of these activities.

During feeding, it helps manipulate food, maintain oral containment, create pressure against the palate, and propel material posteriorly.

When tongue mobility is restricted, patients may experience difficulty with one or more of these functions.

Possible clinical findings include:

• Reduced oral seal
• Difficulty generating suction
• Inefficient bolus formation
• Reduced tongue elevation or lateralization
• Difficulty moving food posteriorly
• Multiple swallows for a single bolus
• Food or liquid escaping from the mouth
• Prolonged feeding times
• Fatigue during meals

These findings are not specific to tongue-tie and may occur with other feeding or swallowing disorders.

A functional assessment is necessary to determine the underlying cause.

The Importance of the Mid-Tongue and Posterior Tongue

Tongue mobility is often discussed in terms of whether the tongue tip can extend beyond the lower teeth.

However, Dr. Smart emphasized that anterior movement is only one part of tongue function.

The middle and posterior portions of the tongue are essential for creating pressure against the palate, maintaining bolus control, and moving food or liquid toward the pharynx.

Effective swallowing requires coordinated contact between the tongue and palate.

This coordination helps maintain oral pressure and prevent premature movement of food or liquid toward the throat.

For myofunctional therapists and feeding specialists, this means tongue assessment should not stop at protrusion.

Clinicians should evaluate elevation, lateralization, posterior movement, coordination, and the patient's ability to perform those movements during functional tasks.

The goal is not simply greater range of motion.

It is more effective function.

Tongue-Tie and Infant Feeding

A comprehensive feeding evaluation considers latch, milk transfer, swallowing coordination, and caregiver concerns.

Feeding is one of the earliest functions in which a tongue restriction may become clinically significant.

Infants must coordinate sucking, swallowing, and breathing while maintaining an effective latch and transferring milk.

The tongue contributes to oral seal, pressure generation, and the movement patterns necessary for feeding.

When feeding is inefficient, families may report:

• Difficulty establishing or maintaining a latch
• Prolonged feeding sessions
• Frequent breaks during feeding
• Poor milk transfer
• Maternal nipple pain during breastfeeding
• Clicking or loss of suction
• Feeding fatigue
• Poor weight gain
• Coughing, choking, or gagging

Dr. Smart emphasized that these concerns deserve careful assessment rather than automatically attributing them to a tongue-tie.

A thorough feeding evaluation should consider the infant's medical history, oral anatomy, feeding coordination, positioning, caregiver concerns, and observed feeding performance.

Some difficulties may improve with lactation support, adjustments to positioning, or other conservative interventions.

Others may require assessment by a pediatric feeding specialist or medical provider.

Recognizing Feeding Red Flags Early

Early identification is especially important when feeding problems affect growth, nutrition, or respiratory safety.

Dr. Smart encouraged families to seek appropriate feeding support when infants demonstrate persistent distress, poor weight gain, unusually long feeding sessions, or repeated coughing and choking.

Feeding sessions that regularly exceed approximately 45 minutes may warrant evaluation, particularly when accompanied by fatigue or inadequate intake.

Coughing, choking, respiratory distress, and poor growth should not be managed with oral exercises alone.

These symptoms may indicate swallowing dysfunction or another medical concern requiring assessment.

For airway-focused professionals, the key is knowing when to refer.

Early intervention may prevent unnecessary feeding stress and help families access the right care before difficulties become more established.

Tongue-Tie and the Introduction of Solid Foods

As infants develop, feeding demands become increasingly complex.

Moving from milk to purees and eventually to more textured foods requires progressive improvements in tongue control, jaw stability, chewing, and oral coordination.

Dr. Smart discussed how tongue lateralization becomes particularly important during the introduction of lumpy and textured foods.

Between approximately nine and twelve months, many infants are developing the ability to manage a broader variety of food textures.

The tongue must move food across the oral cavity, position it over the chewing surfaces, and assist with bolus formation.

Children who struggle with these movements may demonstrate:

• Difficulty moving food from side to side
• Limited acceptance of textured foods
• Prolonged chewing
• Food pocketing
• Fatigue during meals
• Preference for smooth textures
• Difficulty coordinating swallowing

These difficulties may have multiple contributing factors, including sensory processing, oral motor coordination, developmental readiness, or anatomical restrictions.

Clinicians should investigate the underlying cause rather than assuming that tongue-tie is responsible.

The Role of the Glossopalatal Seal

Dr. Smart also highlighted the importance of coordinated tongue-palate contact during swallowing.

The glossopalatal seal helps maintain pressure and control the movement of a bolus through the oral cavity.

When this seal is ineffective, food or liquid may move prematurely toward the pharynx.

This can affect swallowing coordination and efficiency.

For feeding specialists and myofunctional therapists, understanding the relationship between tongue movement, palatal contact, and bolus propulsion is essential.

Assessment should consider both isolated tongue mobility and the patient's ability to coordinate movements during actual feeding.

A patient may demonstrate a particular movement on command but struggle to reproduce it during a complex task.

This distinction is central to functional rehabilitation.

What Does the Research Say About Tongue-Tie Treatment?

Dr. Smart reviewed research examining the impact of tongue-tie treatment on feeding outcomes.

Some studies have reported improvements in breastfeeding-related measures, caregiver confidence, and selected feeding symptoms following frenotomy.

However, findings vary across studies, and not every outcome has been consistently demonstrated.

Differences in patient selection, assessment criteria, surgical techniques, follow-up periods, and outcome measures make it difficult to compare results.

This is particularly important when interpreting studies involving reflux, sleep, speech, or long-term oral development.

An improvement observed after surgery does not necessarily establish that tongue-tie caused the original symptom.

High-quality research is needed to better identify which patients benefit, which outcomes improve, and whether those improvements persist over time.

Why Conservative Management Should Come First

A major focus of Dr. Smart's presentation was the importance of considering non-surgical support before proceeding with frenotomy.

She discussed the Australian Dental Association's 2020 guidance, which emphasizes careful assessment and conservative management before surgical intervention.

Depending on the patient's age and symptoms, non-surgical care may include lactation consultation, feeding-position adjustments, caregiver education, speech-language pathology, feeding therapy, and monitoring of functional outcomes.

The goal is to determine whether the difficulty can be addressed without surgery and whether a restrictive frenulum is truly contributing to the problem.

However, conservative management should not create unnecessary delays when an infant has significant feeding impairment, inadequate intake, or poor weight gain.

The appropriate timeline may vary considerably.

Some infants require prompt multidisciplinary assessment and treatment decisions, while others may benefit from a longer period of conservative support.

Clinical urgency should be determined by feeding safety, nutritional status, growth, and functional impairment.

When Is Frenotomy Appropriate?

Frenotomy may be considered when a restrictive lingual frenulum is associated with significant functional difficulties that have not adequately improved with appropriate conservative care.

The decision should involve a qualified clinician who can evaluate the restriction, consider alternative explanations, discuss expected benefits and risks, and determine whether surgery is indicated.

Dr. Smart emphasized that appearance alone should not determine treatment.

Important considerations include:

• Documented restriction of tongue movement
• Feeding or other functional impairment
• Response to conservative intervention
• Age and developmental stage
• Medical history
• Caregiver concerns and goals
• Potential benefits and risks
• Availability of appropriate follow-up care

A multidisciplinary approach can help ensure that surgical decisions are based on function rather than anatomy alone.

Does the Surgical Technique Matter?

Tongue-tie release may be performed using scissors, a scalpel, or laser-based techniques.

Dr. Smart discussed research comparing surgical approaches and noted that the available evidence has not established a clear overall advantage of one technique over another.

This is an important consideration in a field where specific surgical technologies are sometimes promoted as inherently superior.

Clinical outcomes may depend on multiple factors, including provider training, patient selection, procedural technique, tissue management, complication prevention, and post-operative support.

The choice of instrument should not overshadow the quality of the clinical assessment or the appropriateness of the treatment decision.

Post-Operative Care and Functional Recovery

Post-operative management remains one of the most debated areas of tongue-tie treatment.

Dr. Smart emphasized the importance of follow-up after surgery to monitor healing, feeding function, complications, and whether the original functional concerns have improved.

She discussed review intervals that may include an initial surgical follow-up within one to two weeks and additional assessment around four to six weeks.

These visits provide an opportunity to evaluate tissue healing, mobility, feeding performance, and any persistent difficulties.

The presentation also addressed active wound management, stretching, and post-operative exercises.

Although some clinical studies have explored whether these approaches influence healing or the need for revision, evidence remains limited and practices vary widely.

Routine wound stretching after infant frenotomy is not universally recommended, and clinicians should not assume that aggressive stretching prevents reattachment.

Post-operative instructions should reflect the treating clinician's evidence-informed protocol, the patient's needs, and careful consideration of discomfort and potential harm.

Functional feeding support and appropriate follow-up remain essential components of care.

Feeding Therapy vs. Orofacial Myofunctional Therapy

One of the most clinically relevant distinctions from Dr. Smart's presentation was the difference between infant feeding therapy and orofacial myofunctional therapy.

Although these approaches may overlap, they are not identical.

Traditional active myofunctional therapy requires patients to understand and voluntarily perform specific oral movements.

This generally becomes more feasible as children develop the cognitive, motor, and attention skills needed to follow instructions, often around four years of age or older.

Infants, by contrast, cannot participate in structured exercises in the same way.

Intervention for babies is more appropriately described as feeding therapy or developmentally appropriate oral motor support.

These interventions may involve:

• Feeding observation
• Positioning adjustments
• Latch support
• Caregiver coaching
• Functional oral motor facilitation
• Feeding coordination
• Sensory support
• Monitoring intake and growth

For healthcare professionals, using accurate terminology helps clarify treatment goals, professional responsibilities, and the evidence supporting each intervention.

Tongue-Tie and Speech Development

Tongue-tie is frequently discussed as a potential cause of speech difficulties.

However, the relationship between ankyloglossia and speech development is not straightforward.

Dr. Smart reviewed research comparing children who had received tongue-tie treatment in infancy with untreated children and controls.

A study evaluating children between approximately two and four years of age found no statistically significant differences in several speech-related outcomes, including speech production, intelligibility, and tongue mobility.

These findings challenge the assumption that every child with a tongue-tie requires early release to prevent future speech problems.

Although selected children with significant tongue mobility restrictions may experience functional articulation difficulties, speech concerns should be evaluated directly.

The presence of a frenulum alone does not establish that it is responsible for a speech sound disorder.

Objective Assessment of Chewing and Swallowing

Dr. Smart also discussed the value of standardized tools for evaluating functional oral performance.

One example was the Test of Mastication and Swallowing Solids, commonly known as TOMASS.

TOMASS evaluates how patients manage a standardized solid food, often a cracker, by measuring variables such as:

• Number of bites
• Number of chewing cycles
• Number of swallows
• Time required to consume the food

This provides objective information about chewing and swallowing efficiency.

The test has been studied across a broad age range, including children and adults, with age-appropriate normative data.

For clinicians working with feeding difficulties, objective measures can support clinical reasoning, treatment planning, and outcome monitoring.

Instead of relying entirely on subjective impressions, clinicians can document whether function changes over time.

The Need for Better Tongue-Tie Assessment Tools

Assessment methods are another area where Dr. Smart emphasized the importance of research.

Several tongue-tie assessment tools are currently used in clinical practice, but they differ in what they measure and how reliably they identify functional restriction.

Some focus heavily on appearance.

Others incorporate mobility, feeding, and oral motor performance.

Dr. Smart discussed a recent systematic review examining the reliability and psychometric properties of available instruments.

The Lingual Frenulum Protocol for Infants was highlighted as a comprehensive approach because it incorporates structural findings, isolated oral motor observations, and functional assessment.

The broader lesson is that clinicians should choose tools with demonstrated reliability and validity whenever possible.

No single measurement should replace comprehensive clinical judgment.

Professional Scope and Interdisciplinary Responsibilities

Tongue-tie management often involves multiple healthcare professions.

Dr. Smart discussed professional guidance addressing the roles of speech-language pathologists, dentists, lactation professionals, and other clinicians involved in identifying and managing ankyloglossia.

Speech-language pathologists may evaluate the functional consequences of tongue restriction within their professional scope, including feeding, swallowing, and speech.

However, responsibilities for formal diagnosis, surgical referral, and treatment recommendations vary by jurisdiction, professional regulations, and individual credentials.

Clinicians should follow the standards applicable to their profession and location.

This is especially important because effective tongue-tie care requires clear communication between professionals.

A feeding specialist may identify functional difficulties. A dentist or surgeon may evaluate the anatomical restriction. A pediatrician may monitor nutrition and growth.

Working together reduces the risk of unnecessary treatment and helps ensure that important symptoms are not overlooked.

Why Long-Term Research Matters

Dr. Smart concluded by emphasizing the need for stronger clinical research and more consistent outcome tracking.

Tongue-tie management remains an area where professional practices vary significantly.

Different clinicians use different diagnostic criteria, treatment thresholds, surgical approaches, and post-operative protocols.

Without standardized assessment methods and comparable outcome measures, it becomes difficult to determine which interventions provide meaningful benefits.

Dr. Smart discussed the development of an international multidisciplinary research initiative intended to support multicenter studies and improve the evidence available to clinicians.

This collaborative approach may help address important unanswered questions, including:

• Which infants benefit most from frenotomy?
• Which functional measures best predict treatment outcomes?
• How effective is conservative feeding support?
• What post-operative care is necessary?
• Do early improvements persist over time?
• How should swallowing and speech outcomes be measured?
• Which patient characteristics influence recovery?

The future of tongue-tie management depends on answering these questions through rigorous research rather than relying exclusively on clinical impressions.

Clinical Questions for Healthcare Professionals

When evaluating a patient with suspected tongue-tie, clinicians may consider asking:

• Is the lingual frenulum actually restricting movement?
• Does the patient demonstrate functional impairment?
• Can the tongue elevate, lateralize, and coordinate movement?
• Is the restriction affecting feeding, chewing, swallowing, or speech?
• Has the infant undergone a comprehensive feeding assessment?
• Are there signs of poor milk transfer or inadequate weight gain?
• Does the child struggle with age-appropriate food textures?
• Could another condition explain the symptoms?
• Has appropriate conservative care been attempted?
• Is surgical intervention clinically indicated?
• What outcomes will be measured after treatment?
• Is a post-operative follow-up plan in place?
• Does the patient need support from another specialist?

These questions help providers move beyond visual classification and focus on the patient's functional needs.

Key Takeaways for Healthcare Professionals

Tongue-tie should be diagnosed through a combination of structural and functional assessment, not appearance alone.

A visible or palpable lingual frenulum is a normal anatomical finding unless it restricts movement and contributes to functional impairment.

Research suggests ankyloglossia affects approximately 8% of infants and children, although prevalence varies according to diagnostic criteria.

Tongue mobility is important for oral seal, bolus formation, swallowing, and the transition to textured foods.

The mid-tongue and posterior tongue play essential roles in coordinated oral movement and swallowing.

Feeding concerns should be assessed comprehensively before being attributed to tongue-tie.

Non-surgical feeding and lactation support should be considered before surgical intervention when clinically appropriate.

Scissors, scalpel, and laser approaches have not demonstrated consistent superiority across all clinical outcomes.

Post-operative follow-up is essential, while the benefits and risks of routine wound stretching remain under investigation.

Infant feeding therapy and active orofacial myofunctional therapy are different approaches and should be described accurately.

Tongue-tie does not automatically cause speech disorders, and prophylactic release to prevent future speech problems is not supported by strong evidence.

Standardized assessment tools, objective functional measures, and multidisciplinary research are essential for advancing clinical care.

The Airway Circle Perspective

Interdisciplinary collaboration helps families receive individualized, evidence-informed tongue-tie care.

At Airway Circle, we believe the best clinical decisions begin with a thorough understanding of function.

Dr. Sharon Smart's presentation reinforces something that is fundamental to orofacial myofunctional therapy: anatomy and function must always be evaluated together.

A tongue may appear restricted but function adequately.

A patient may have significant feeding difficulties without tongue-tie being the primary cause.

And a surgical release may improve mobility without automatically resolving every feeding, swallowing, or oral motor concern.

This is why interdisciplinary collaboration matters.

Myofunctional therapists, speech-language pathologists, lactation professionals, dentists, pediatricians, ENTs, and feeding specialists each contribute valuable information to the clinical picture.

When providers communicate clearly, use reliable assessments, and focus on meaningful outcomes, families are better supported in making informed decisions.

The goal is not to perform more procedures.

The goal is to provide the right care to the right patient at the right time.

Final Thoughts

Tongue-tie management continues to evolve as new research challenges assumptions and helps clinicians refine their approach.

Dr. Smart's presentation reminds us that successful treatment is not defined by whether a frenulum was released or whether tongue mobility increased on examination.

The deeper question is whether the patient's function improved.

Can the infant feed more effectively?

Can the child manage age-appropriate textures?

Has swallowing become more coordinated?

Has discomfort decreased?

Are families experiencing meaningful improvements in daily life?

These are the outcomes that matter.

By prioritizing functional assessment, individualized management, objective measurement, and interdisciplinary collaboration, healthcare professionals can continue moving tongue-tie care toward a more consistent and evidence-informed standard.

The future of tongue-tie treatment is not about identifying more restrictions. It is about understanding which restrictions matter and how best to help the patients affected by them.

Need Guidance With Tongue-Tie, Feeding, or Myofunctional Therapy?

Finding the right support for tongue-tie concerns, feeding difficulties, swallowing problems, oral restrictions, or orofacial myofunctional disorders does not have to feel overwhelming.

Whether care involves feeding therapy, lactation support, speech-language pathology, pediatric dentistry, ENT evaluation, myofunctional therapy, or a surgical consultation, the goal is to understand the underlying concern and determine the most appropriate next step.

With the right guidance, patients and families can make informed decisions and work toward better oral function and quality of life.