The Feed That Makes You Wonder
It's the third bottle of the shift and the baby is working hard again. Two or three sucks, a pause, a little drop in saturation, milk pooling at the corner of the mouth. Somebody at the bedside peeks under the tongue and asks the question out loud: could this be a tongue tie?
Here's the short version. In a preterm infant, immaturity explains most feeding struggles, and many of them ease with time, growth, and skilled support. A tongue tie in the NICU is possible, but it is judged by how the tongue works once a baby is physiologically ready to feed, not by how the frenulum looks on day four. The skill that matters most is telling the two apart.
At Latched Beginnings in Austin, Dr. Kacie Culotta, DMD, evaluates infant feeding and oral function, and we work alongside the nurses, IBCLCs, speech-language pathologists, and occupational therapists who supported them first. We respect how much expertise already lives in the NICU. Here's how we think about oral ties in this setting, and where a referral fits.
Why Is Preterm Feeding So Hard to Read?
Oral feeding is one of the last skills a preterm baby masters. The ability to coordinate sucking, swallowing, and breathing generally emerges around 32 to 34 weeks postmenstrual age, and readiness looks different from baby to baby. Stable breathing and heart rate, an alert state, rooting, hand-to-mouth activity, and effective non-nutritive sucking are the cues many units watch for before starting oral feeds.
That means a baby can look like a poor feeder for reasons that have nothing to do with the frenulum: low tone, limited stamina, respiratory support, reflux, or simply being early. Research backs up how tricky this is. A multicenter study of neonatal nurses published in BMC Nursing found notable knowledge gaps around oro-motor function, the suck-swallow-breathe pattern, and non-nutritive sucking, and called for more training and support. Nobody is expected to read these feeds perfectly alone, which is why a team approach helps.
Immaturity or Restriction? What to Watch For
There's no single sign that settles it, and a quick visual check can mislead in either direction. These patterns can help you decide whether a baby's struggle looks more like maturation or more like a mechanical limit worth a closer look.
Pattern over time
Immaturity usually improves week by week as the baby grows, gains stamina, and weans off respiratory support. A restriction tends to stay stubborn even after endurance, state control, and coordination have caught up.
Where the fatigue comes from
A preterm baby who tires globally, loses tone, and drifts off is often telling you about stamina. A baby who is alert and organized yet can't extend, lift, or cup the tongue well enough to hold a seal is telling you something different.
Tongue movement during a real feed
Watch function, not just appearance. Can the tongue come forward over the lower gum, lift toward the palate, and move side to side? A restriction is often felt more than seen, so a trained provider's hands-on assessment during and around a feed matters.
Seal, clicking, and milk loss
Repeated loss of suction, clicking, and dribbling can come from weak tone, a fast-flowing nipple, or tongue restriction. Try flow and positioning changes first, then note whether the pattern persists.
Breast versus bottle
Some babies manage a bottle but struggle at the breast, or the reverse. That difference is useful information to pass along, since each asks slightly different things of the tongue.
When Is It Too Early to Assess or Refer?
Timing decisions belong with the medical team. A baby who is still unstable, still on significant respiratory support, or not yet showing consistent feeding readiness can't give anyone a fair picture of tongue function. Assessing too early risks labeling immaturity as a tie, and the reverse can happen when a real restriction gets lost among other problems.
In practice, a functional evaluation makes the most sense once a baby is feeding orally with some consistency and the team has already addressed flow, positioning, pacing, and stamina. The 2024 AAP clinical report on ankyloglossia also puts evaluation and lactation support ahead of any procedure, which fits the NICU well. For many families, the right moment to see us comes after discharge, and our parent-facing guide to feeding your NICU graduate when tongue-tie is a question walks them through what that looks like.
Some findings call for the neonatologist or pediatrician first, not a tie referral: poor weight gain, signs of dehydration, color changes or breathing trouble with feeds, suspected aspiration, or neurologic concerns. A release never treats reflux disease, torticollis, allergy, or neurologic conditions, so those need their own workup.
What to Document Before a Referral
Good notes save the family from repeating the story and help the next provider see what the NICU team saw. Consider noting:
- Gestational age at birth, current postmenstrual age, and when oral feeds started
- Respiratory support history and any events during feeds
- Feeding method, nipple or flow rate, positioning, and pacing strategies already tried
- What you observed about tongue extension, elevation, lateralization, and seal
- How the pattern has changed, or not changed, over the past one to two weeks
- Weight trend and how much of each feed is taken orally
If you'd like a fuller template, our guide to tongue-tie referral documentation covers what to write and include.
Talking With NICU Families Without Adding Alarm
NICU parents are already carrying a lot. Hearing "tongue tie" from one person and "he's just early" from another can leave them feeling lost. A calm, shared message helps: we're watching how feeding develops, many preterm babies improve as they mature, and if the tongue still seems to be limiting feeding once your baby is ready, a functional evaluation can answer that question.
Try to avoid promising either outcome. Not every baby needs a release, and a release is only one part of a feeding plan when it is needed. For more language you can borrow, see what to tell families before you refer.
Partnering With Latched Beginnings in Austin
You spend hours at the bedside learning each baby's cues, and you know when a feeding pattern doesn't fit the usual story. When a restriction is still a real question after discharge, we're glad to take a careful second look and share what we find with you.
Dr. Kacie Culotta, DMD, is the only dentist in Austin who holds both a laser certification for tongue-tie releases and a lactation counselor certification, and she has spent more than 10 years helping infants and families. Our evaluations focus on function, including watching a feed, and we coordinate with IBCLCs, pediatricians, SLPs, and bodyworkers. When a release is appropriate, we use a LightScalpel CO2 laser and give each family a customized aftercare plan with follow-up. When it isn't, we say so and help families find the right next step.
Our patient referral forms make it simple to send a family our way with your notes attached. We're here to guide you every step of the way.
Frequently Asked Questions
Can you diagnose a tongue tie in the NICU?
A frenulum can be noted in the NICU, but whether it limits feeding is best judged once a baby is showing consistent feeding readiness. Before about 32 to 34 weeks postmenstrual age, suck-swallow-breathe coordination is still developing, so poor feeding usually reflects immaturity rather than restriction.
Should a preemie have a tongue tie release before NICU discharge?
Most preterm babies don't need one, and the timing of any procedure is a decision for the medical team. Many feeding struggles ease as babies mature, so a functional evaluation after discharge, once feeding has settled into a pattern, often gives a clearer answer.
How do I tell a weak suck from a tongue tie in a preterm infant?
Watch the trend and the tongue together. Weak suck from immaturity usually improves over one to two weeks as stamina grows, while a restriction shows up as limited tongue extension, elevation, or seal even when the baby is alert and organized.
Who should do a preterm infant tongue tie assessment?
A trained provider who evaluates function, such as an IBCLC, feeding-trained SLP or OT, pediatric dentist, or physician experienced with oral ties. The strongest assessments combine a hands-on oral exam with watching a real feed, whether at the breast or bottle.
Does a lip tie cause feeding problems in preemies?
The evidence linking lip ties to feeding trouble is weak, and major professional groups are cautious about releasing them for feeding. Focus on tongue function, flow, positioning, and stamina first, and bring concerns about the lip to the evaluating provider.
What should a NICU nurse tell parents who ask about tongue tie?
Tell them honestly that feeding is still developing and that the team is watching. Explain that many preterm babies improve as they mature, and that if concerns persist after discharge, a functional evaluation can clarify things within a few weeks of home feeding.
Where can NICU teams refer for a tongue tie evaluation in Austin?
Latched Beginnings sees infants at 1701 Simond Ave, Suite 107A, in the Mueller area of Austin, and welcomes referrals from NICU nurses and feeding therapists. We serve families from Austin, Round Rock, Cedar Park, Pflugerville, Leander, Georgetown, and nearby communities. Call (512) 814-7480.
Call to Action
If you're caring for a preterm baby and wondering whether a tongue tie in the NICU is part of the feeding picture, you don't have to sort it out alone. Reach out to coordinate care, request our referral forms, or ask about provider coaching, and we'll work with your team so every family leaves with a clear, gentle next step.
