By Josée Pound, IBCLC, B.A. | Lactation Consultant, Pasadena, CA
If you've found your way to this post, you're probably in the thick of it. Maybe breastfeeding is painful. Maybe your baby is gassy, fussy, or not gaining weight the way your pediatrician hoped. And maybe someone — a friend, a nurse, a post in a Facebook group — has suggested that your baby might have a tongue tie.
Tongue tie is one of the most searched topics in the breastfeeding world right now, and it's also one of the most misunderstood. As an IBCLC practicing in the Pasadena and Los Angeles area, I see families navigating this question every week — and I want to offer you something that the internet often doesn't: a calm, evidence-based, honest picture of what tongue tie is, what it isn't, and how to figure out what's actually going on with your baby.
What Is a Tongue Tie, Really?
Every single baby is born with a frenulum — a small band of connective tissue under the tongue that connects it to the floor of the mouth. This is completely normal anatomy. The frenulum's job is to support the tongue and limit extreme movements.
For approximately 5–10% of babies, the process of tongue separation during fetal development is disrupted, resulting in a frenulum that is shorter, thicker, or less elastic than typical. This is called ankyloglossia, or tongue tie. The presentation can vary enormously — from a tight band that visibly tethers the tip of the tongue to the lower jaw, to a subtler restriction deeper in the mouth (sometimes called a posterior tongue tie).
Here is the most important thing, just seeing a frenulum under an infants tongue does not mean it is restricting. A baby can have visible tissue under the tongue and breastfeed beautifully. And a baby can have a subtler restriction that significantly impacts feeding. This is exactly why a comprehensive, functional assessment matters — not a quick glance during a well-baby check.
The Problem with Social Media and Tongue Tie
Tongue tie has become a cultural moment. TikTok, Instagram, and parenting forums are full of parents sharing photos of their babies' mouths, asking strangers whether a frenulum 'looks tied.' Well-meaning friends share their own frenectomy stories as a reason your baby might be struggling. Pediatricians who aren't trained in lactation assessment sometimes check a quick box at the two-week visit and say it looks fine — or, conversely, refer immediately for a procedure.
The challenge is that diagnosing a functional tongue tie is genuinely complex. It requires looking at the full picture: the anatomy, yes — but also how the baby is using their tongue, how they're transferring milk, and whether the mother is experiencing pain. In my clinical work, I often see babies referred for possible tongue tie release who are actually struggling because of latch positioning, a fast or slow letdown, or something as straightforward as the way they're being held at the breast.
The reverse is also true. I see babies who have been cleared at the pediatrician's office who do have a functional restriction that is genuinely getting in the way. This is not a condition you can reliably diagnose from a photo — or even from a single-discipline assessment.
What Tongue Tie Can Look Like in Breastfeeding
There are signs that may suggest a tongue tie is contributing to feeding challenges. None of these signs, on their own, confirms a tongue tie diagnosis — they are reasons to seek a thorough evaluation.
Signs the parents might notice:
· Nipple pain that persists beyond the first few days and doesn't improve with positioning adjustments
· Nipples that appear compressed, creased, or "lipstick-shaped" after a feed
· The sensation of baby "chomping" or chewing rather than drawing milk effectively
· Prolonged feeding sessions with a baby who never seems satisfied
· Frequent blocked ducts or decreased milk supply over time
Signs the baby may show:
· Difficulty maintaining a deep latch, or repeatedly sliding off the breast
· Clicking or smacking sounds during feeding (a sign of lost suction)
· Milk spilling from the corners of the mouth
· Visible gassiness and discomfort, particularly if excess air is being swallowed
· Poor weight gain despite frequent nursing sessions
· A baby who seems to nurse constantly but is not actually transferring milk well
Dr. Chelsea Pinto, a dentist and educator who specializes on infant and toddler tongue and lip ties patient explains, when a tongue cannot adequately extend, cup, and compress breast tissue, a baby may be unable to create the negative pressure needed to remove milk efficiently. This can cause the baby to clamp down on the nipple — which explains the pain many mothers feel — and may result in a feeding that takes a long time but transfers very little milk.
One of the more nuanced signs worth understanding is the clicking sound during feeding. Dr. Bobby Ghaheri, MD — an otolaryngologist (ENT surgeon) in Portland, Oregon who has dedicated his practice to tongue tie and breastfeeding medicine, and who is one of the most published researchers in this field — explains that a click happens when the tongue loses its seal against the breast. When the tongue cannot stay elevated as the jaw drops during a suck cycle, it breaks contact and air enters the system. This swallowed air (aerophagia) is a significant driver of infant gas, fussiness, and reflux-like symptoms. Importantly, Dr. Ghaheri also notes that a click does not automatically mean tongue tie — muscle tension, positioning, palate shape, and tongue tone can all contribute. The cause has to be properly investigated.
You can read more about his research and clinical approach at drghaheri.com.
The International Breastfeeding Centre in Canada (Dr. Jack Newman's clinic) also highlights that tongue tie is one reason — among several — that can contribute to late-onset decreased milk supply, typically noticed around two to four months. When a baby's latch is subtly ineffective due to a tongue restriction, the breast may not be fully emptied over time, and supply can quietly drop over months. If you've noticed your previously content, well-gaining baby suddenly fussing at the breast and not seeming satisfied, this is worth exploring with an IBCLC.
The Three Questions I Ask Before Considering a Referral
When a family comes to me with concerns about tongue tie, the most important questions are not anatomical — they are functional.
1. Can the baby transfer milk effectively?
2. Is the mother pain-free?
3. Is the baby gaining weight well?
If the answer to all three of those questions is yes — feeding is going well, mom is comfortable, and baby is growing — then the presence of a frenulum alone is not a reason to proceed with a frenectomy. Tissue does not equal restriction. Function is everything.
When a Referral for Assessment Makes Sense
If breastfeeding is painful and positioning adjustments haven't helped, if a baby is not gaining weight despite frequent nursing, or if we're seeing consistent signs of poor milk transfer — then I do refer for a specialist evaluation. In the greater Los Angeles and Pasadena area, I am grateful to work alongside practitioners I trust deeply.
Dr. Jessica Choi, DMD — San Marino Pediatric Dentistry
Dr. Choi practices in San Marino, CA, just minutes from Pasadena. She is a Diplomate of the American Board of Pediatric Dentistry and offers frenectomy services as part of a thoughtful, family-centered practice. She understands the breastfeeding relationship and the importance of an individualized approach to each baby. Learn more at sanmarinopediatricdentistry.com.
Dr. Chelsea Pinto, DDS
Dr. Pinto practices in Woodland Hills, CA, and has dedicated her entire practice to infant tongue and lip ties. She is one of very few dentists in Los Angeles who has solely focused on this area, having treated thousands of babies with oral restrictions. Her assessment is based on functional limitation, not just anatomical appearance — and she emphasizes collaborative care, wanting an IBCLC or feeding specialist to have already seen the baby before any evaluation. Learn more at drchelseapinto.com.
Dr. Bobby Ghaheri, MD
For families outside the LA area — or those who want to go deeper into the research — Dr. Ghaheri is an ENT surgeon at The Oregon Clinic in Portland and one of the leading researchers in tongue tie and breastfeeding medicine in the United States. His published studies, including a prospective randomized controlled trial on posterior tongue tie release, have helped establish the scientific foundation for understanding how tongue restriction affects infant feeding. He also emphasizes that working with an IBCLC before any procedure is not optional — it's essential. His resources are at drghaheri.com.
All three of these practitioners support the kind of collaborative, team-based approach that I believe gives families the best outcomes: IBCLC assessment first, specialist evaluation when clinically indicated, and ongoing lactation support after any procedure.
What About Frenectomy? What Parents Should Know
A frenectomy — sometimes called a tongue tie release — is a minor procedure that involves releasing the frenulum to allow greater tongue mobility. When it is genuinely indicated, it can make a meaningful difference. Families often report improvement in latch and comfort quite quickly following the procedure.
But a frenectomy is still a procedure. While it can reduce maternal pain and improve feeding when a true functional restriction is present, outcomes depend heavily on proper diagnosis, timing, and follow-up support. The procedure addresses an anatomical limitation — but if the baby's underlying oral motor skills need further development, bodywork or feeding therapy after the procedure may be part of the plan. Dr. Jessica Choi’s treatment framework may involve referral to occupational therapy and continued support with an IBCLC. A frenectomy should never be the first step — or the only step.
The Bottom Line
Tongue tie is real. It affects a meaningful percentage of babies and can genuinely complicate breastfeeding when a true functional restriction is present. But not every frenulum is a problem, and not every breastfeeding challenge points to tongue tie.
A thorough assessment, including a breastfeeding observation with a skilled IBCLC who can evaluate latch, milk transfer, nipple pain, and infant weight gain together. If the feeding system is working — even with visible tissue — there may be nothing that needs to change. If there are genuine concerns, a referral to a specialist like Dr. Choi gives families the clearest possible picture before any decision is made.
You deserve care that looks at the whole story, not just a photo of the inside of your baby's mouth.
If you're in the Pasadena or Los Angeles area and have questions about your baby's latch, milk transfer, or a possible tongue tie referral, I'd love to support you. Click here for support or to book a consultation: https://joseepound.com/book
Referenced Resources:
Dr. Chelsea Pinto, DDS — drchelseapinto.com | Frenectomy Overview: What Parents Need to Know (PDF)
Dr. Jessica Choi, DMD — San Marino Pediatric Dentistry — sanmarinopediatricdentistry.com
Dr. Bobby Ghaheri, MD — ENT Surgeon & Tongue Tie Researcher — drghaheri.com
International Breastfeeding Centre (Dr. Jack Newman) — Late Onset Decreased Milk Supply or Flow
Josée Pound is an International Board Certified Lactation Consultant (IBCLC) serving families in Pasadena, Los Angeles, and the surrounding communities. This post is for educational purposes and is not a substitute for individualized medical or lactation advice.