Shira Johnson, IBCLC
What's a tongue tie?
Updated: Nov 18, 2021
All About Tongue Tie, Lip Tie, Breastfeeding & Beyond
Shira Johnson, IBCLC Shira Johnson Lactation LLC
What is a tongue tie?
Tongue ties and lip ties are examples of oral restrictions.
Everyone has a bit of connective tissue, a frenulum or frenum, that connects the underside of the tongue to the floor of the mouth. The presence of this frenulum is normal. Even the appearance of the frenulum is not necessarily suggestive of a problem (it’s difficult or impossible to diagnose ties from a photograph).
There are also frenula (bits of connective tissue) connecting the lips to the gums, and the cheeks to the gums. Restrictions, or ties, can occur in any of these attachments.
Again, the presence of these attachments is normal. What is problematic is when the position, tension or length affects the ability for these parts to function well with full range of motion.
Tongue ties are estimated to affect roughly 10% of the population, but the incidence may be much higher than this. More studies are needed, and are currently being done, to help with our identification and understanding of tongue tie, and the risk factors, genes and epigenetic factors behind it.
A frenulum is problematic when it limits the tongue’s range of motion.
If a frenulum/frenum is restricting the tongue’s function, it is considered a “tongue tie”, or akyloglossia.
The same can be true for lips, if the frenum attaching the lip to the gum is short, thick or tight enough to prevent the lip from its full ideal range of motion. (Lip ties occasionally but rarely occur without the presence of a tongue tie; usually when there is a lip tie, there is also a tongue tie).
Tongue and lip ties (and even sometimes cheek or “buccal” ties) can limit baby’s ability to achieve a latch that is comfortable (for mom and/or baby) and effective for transferring milk.
Tongue ties can affect more than just a baby’s ability to latch. They can also impact general comfort, breathing, swallowing, digestion, eating, speech, etc., during infancy, childhood and throughout life.
Common Symptoms of Tongue Tie & Other Oral Restriction:
NOTE: Not all of these symptoms need to be present for a restriction to be present!
Likewise, these symptoms don’t always indicate a tongue tie – other issues can cause most of these symptoms. Consulting with an experienced IBCLC/lactation consultant can help determine the cause, and best treatment for any symptoms you’re experiencing. (Unfortunately not all lactation professionals are highly trained this, and same goes for pediatricians and other physicians – many are not specifically trained at assessing the fine motor function of baby’s mouth, and ties are often overlooked or inaccurately ruled out). If a provider has ruled out a tongue tie by simply looking with their eyes and has not put fingers in and palpated under baby’s tongue, the assessment is incomplete. If ties have already been “ruled out” by a provider and you’re still experiencing some of these symptoms, consider getting another opinion.
o Nipple Pain – sensations of pinching, biting, compression, friction on nipple while nursing
o Nipple Damage – broken skin, scabs, open wounds on the nipple
o Nipple Compression – nipple looks flat, angled (“lipstick-shaped”), or discolored after nursing
o Difficulty latching (fussing at breast, frequent unlatching, even refusal to latch) -
Babies with restrictions are often unable to open their mouths widely or maintain suction, so nursing may be uncomfortable or exhausting for parents and baby. They may be considered "lazy". But the truth is, babies do the best they can. They aren’t stubborn or lazy – they are struggling and need some support.
o Unable to hold a pacifier – frequently loses/drops a pacifier, or appear to dislike pacifier
o Clicking sounds while nursing
o Very long nursing sessions (regularly more than 40 minutes)
o Baby frequently falls asleep at breast before finishing a feeding
o Baby is often fussy or frustrated while feeding, rarely seems relaxed or satisfied after feeding
o Low/slow infant weight gain
o Shallow latch; parents report “baby won’t open mouth wide” or “baby latches on the nipple”
o Coughing/choking while feeding or Sensitive gag reflex
o Dribbling/leaking of milk from baby’s mouth
o Frequent Hiccups, Gas, Reflux symptoms -baby may have been prescribed medication for reflux
o Mouth breathing, frequent snoring/snorting/squeaky breathing sounds
o “High Needs Baby” – tension and discomfort caused by oral restrictions can cause babies to be hard to soothe, to need more support from caregivers (holding, bouncing, rocking, etc.)
The Who/What/Why/When/Where/How about getting evaluated for oral restriction:
Why get assessed if tongue tie is suspected?
Tongue tie doesn’t always result in breastfeeding difficulty. (Or things may appear to be going well for some time --good weight gain, no maternal pain, etc.--, and then gradually decline, often between 2-3 months of age).
Furthermore, tongue tie can impact much more than feeding.
Even if feeding is going well enough, or breastfeeding is not a priority, it can still be worth looking into.
Tongue tie in older children/adults has been associated with:
o Speech issues (limited range of tongue motion can limit certain speech sounds)
o Difficulty with solid foods: pickiness about textures, disinterest in food, frequent choking/gagging
o Dental/orthodontic issues (Tongue’s job is to keep the mouth clean & shape the oral cavity, airway & face)
o Airway issues (snoring, mouth breathing, sleep apnea)
o Muscular tension, neck pain, headaches/migraines, TMJ, etc.
What to expect: Who to see & How to prepare for evaluation?
*( See separate blog post about important PREPARATION before a frenectomy!) https://www.shirajohnsonlactation.com/post/getting-a-tongue-tie-release-how-to-prepare
1. You should first see an IBCLC to address latch/oral function and positioning, and a bodyworker to address any structural issues baby may be experiencing in their body.
2. If a tie is apparent, or if issues persist, you may then choose to see a dentist or other release provider to diagnose, treat or rule out any ties. It’s important to select a provider who’s experienced with ties - Not all are! Some providers require a referral, which you can get from an IBCLC, MD, midwife, bodyworker, etc.
3. When you see a release provider (dentist or ENT) for evaluation, expect a brief exam, where they examine baby’s mouth, look and feel under/around baby’s tongue/lips/cheeks, assess the function of the tongue (strength, range of motion, etc.), note any other signs associated with ties (high palate, gag reflex, etc.).
4. If a tie is detected/dianosed, many providers will offer the option of doing the procedure right then and there (WAIT - is baby well-prepared? see separate preparation blog post!), or you may schedule the release for a later date. Depending on your situation, you may wish to wait and do some preparation first! (HOW TO PREPARE?https://www.shirajohnsonlactation.com/post/getting-a-tongue-tie-release-how-to-prepare)
Ties can be released with a laser, scalpel or scissors. The procedure can be done well with any of these tools- it is the skill of the provider that is more important than the tool that is used. Most providers who do frenectomies frequently opt to use a laser.
Some providers apply topical local anesthetic to the area, whereas some providers do not use any anesthetic, as they feel it is not necessary. (If a provider tells you that general anesthesia is recommended, seek an alternate opinion, as this is not necessary for doing this procedure on babies, and can pose additional risks.) The procedure itself is very short, generally taking 2-10 minutes total.
If a laser is used, anyone in the room (baby, doctors, parents, etc.) is required to wear laser safety goggles, and some providers will not allow parents in the room with the laser.
Some providers allow parents in the room for the procedure, some do not.
Aftercare (and Preparation!): The importance of a team approach.
*The best outcomes from a procedure (known as frenotomy/frenectomy) incorporate a team of providers who provide collaborative care, addressing and supporting baby’s function & structure in multiple ways.
A good team for treating oral restrictions includes:
An experienced board certified lactation consultant helps optimize latch & positioning, in addition to assessing tongue movement and general oral function for breastfeeding. They should provide exercises for oral strengthening and coordination to help prepare for frenectomy, and make progress after the procedure.
Note: Not all IBCLCs or lactation professionals have this knowledge or specialize in working with ties or the frenectomy procedure. They should be able to make custom recommendations for other necessary providers (bodyworkers, occupational therapists, etc.) , depending on the issue(s) being experienced.
2. Release Provider (usually a specially-trained Dentist or ENT)
Many providers can & will do a release procedure, but it’s best to select a provider who has the best training and experience to properly assess and release the ties well & thoroughly. This is very important. (I've worked with many clients who have had incomplete releases done, only to need to go have them released again by a more experienced provider).
I recommend asking around for word-of-mouth recommendations in your community, and asking any potential release providers how many releases they do per week or per month. If it is just a few per year, you may want to look elsewhere. Also ask whether they release “posterior ties”, and whether recommend any “aftercare exercises”. If they say no to either, seem confused by the question or don’t have a clear answer, they're probably not particularly knowledgeable about the whole process.
Many providers can release a tie, but if they are done incompletely, or if more is cut than necessary, this can result in an incomplete release or cause unnecessary discomfort. General anesthesia or stitches are not typically used in a routine procedure for a frenotomy procedure for a baby. If your provider says these are necessary, seek another opinion.
3. Skilled bodyworker (e.g. chiropractor, craniosacral therapist, osteopath, physical therapist)
Seeing someone who can treat the body as a whole, help release tension and support optimal movement will help optimize oral function.
Breastfeeding involves many nerves, muscles and reflexes; it takes a complex set of actions to coordinating sucking, swallowing and breathing! When restrictions or ties are released, there are usually compensations or unhealthy habits that need to be “unlearned” as baby learns the new correct movements.
Additionally, by supporting more space and movement and less tension in baby’s body, we allow the mouth to heal into a space that allows for full range of motion. Even when there’s been a release, if tension and old habits remain in the body, the release itself may not result in any improvement. For breastfeeding to go smoothly, baby’s nervous system/reflexes, muscles, structural alignment, and all the many structures of the mouth need to be working well and in harmony!
What to expect after baby’s release procedure (frenectomy)
o Realistic Expectations:
· Baby may nurse immediately after the procedure. Latch may or may not initially feel different.
It’s normal not to notice a difference immediately. Improvement can take several weeks!
· Baby may cry, be very fussy and/or sleepy for ~24 hours after release.
· Baby may refuse nursing/feeding for part of the first day after release. Don’t worry.
They typically return to normal within 24-48 hours. If you’re concerned, watch for signs of dehydration and contact your release provider, pediatrician or ER with any major concerns.
· The wounds resulting from tongue or lip release should be diamond-shaped; You should be able to visualize this.
· As the wounds heal, a white/yellow scab will appear. This is normal; doesn’t indicate infection.
· If often takes 3-6 weeks to see significant improvement after a release.
Progress usually doesn’t happen overnight! It can feel discouraging, but progress might be slow.
Proper aftercare within the weeks following release are critical to optimal results (see below).
o Pain management:
Some babies require no pain relief, but some need more active support for discomfort for 1-7 days following release:
· Skin to Skin, lots of snuggling, baby wearing
· Homeopathic Arnica Montana (pellets dissolved in water) & other homeopathic remedies
· Rescue Remedy
· Frozen Breastmilk chips under tongue
· Tylenol- Many providers still recommend Acetominophen, but please be aware of potential dangers &
negative side effects from Tylenol:
o You should receive instructions from your IBCLC & release provider for:
· Active wound care; “stretches/lifts” prevent wound from healing too quickly or reattaching.
These should be done 4-6x/day for 2-3 weeks.
· Oral exercises & games to strengthen & achieve optimal mobility (IBCLC will teach these).
To be done 3-5x/day for several weeks. Follow up with IBCLC as function improves/changes, as recommended exercises may change.
· Bodywork – Bodywork before and after frenectomy is an integral part of the process. Habitual compensations or tension in baby’s body influence how the mouth moves. Therefore, release (frenectomy) alone may not result in any improvement without complementary care. The release alone is just part of the process to achieve good function.
After release, a new frenulum eventually grows. This is normal. The above steps ensure that there is adequate mobility & space for a new frenum to grow long enough to allow for full range of motion!
RECOMMENDED PEDIATRIC BODYWORKERS IN WEST MICHIGAN:
Kelly OBrien St Brigid’s Craniosacral Therapy https://www.stbrigidscst.com/
Theresa Osmer DC Flow Chiropractic https://www.flowchiro.com/
Rise Wellness https://www.risewellnesschiro.com/
Thrive Chiropractic http://www.thrivechirocenter.com/
Dr Benjamin Visger DO & Dr Paul Dybal DO
Richard Holshoe Craniosacral Therapy https://richard-holshoe-craniosacral-therapist.business.site
Molly Kehoe at Holistic Care Approach - Craniosacral therapy https://www.holisticcareapproach.com/practitioner/molly-kehoe/
Darren Grunwaldt DO, Metro Health
Dr Charles Lietz (616) 530-3333
Tonya Westerbeke DC Back to Health Zeeland, MI
Jessica Ireland Ireland Chiropractic Coopersville, MI
RECOMMENDED RELEASE PROVIDERS IN WEST MICHIGAN:
· Mitten Kids Dentistry - Grand Rapids/Caledonia https://www.mittenkids.com
· Pediatric Dental Specialists of West Michigan - Grand Rapids https://www.pdsofwestmi.com
Release providers elsewhere in the region:
· Discover Smiles Pediatric Dentistry, Okemos, MI (Dr. Ramaswami)
· Princess City Dental, Mishawaka, Indiana (Dr. Poulsen)
General Tongue Tie References & Resources:
Dr. Bobby Ghaheri: https://drghaheri.com
Dr. Mikal Newman: https://www.newmanfamilydentistry.com/frenectomy.html
Dr. Larry Kotlow: https://www.kiddsteeth.com/breastfeeding.php
Dr. Richard Baxter: https://tonguetieal.com/tongue-ties/
Internat. Affiliation of Tongue-Tie Professionals: https://tonguetieprofessionals.org/about-tongue-tie/
Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/tongue-tie/symptoms-causes/syc-20378452
Book: Tongue Tied by Richard Baxter & other contributing authors.
Please reach out with any questions about tongue tie, with or without breastfeeding.
I am experienced & passionate about this topic, and happy to help.