I started doing more research on Tongue and Lip Ties a few years ago and quickly learned no one in my small town was concerned or addressing oral restriction in babies. I could never understand the black cloud that seemed to loom over the topic. There were concerns about over diagnosing or chatter that this was "fad" and we should ignore until it went away.
But it didn't go away.
Families were being tossed around to different providers, often with no help or diagnosis and commonly ending up pumping exclusively, formula feeding and feeling unheard. It made me delve into the taboo topic; searching for online studies, books, in-person conferences and hands on training.
So let's delve in!
In this blog I will address Tongue and Lip Ties as "oral restriction" (it is also called Ankyloglossia.) It is described as "an embryological remnant of tissue in the midline between the undersurface of the tongue and the floor of the mouth that restricts normal tongue movement." Retrieved from - International Affiliation of Tongue Tie Professionals
(I am not going to delve into classes of restriction, different kinds of ties etc. There are great blogs and more information from leading specialists, I like Dr. Ghaheri's blog posts!)
Click here for more information on Lip Ties.
Everyone has a Frenulum!
Yes! Everyone has a frenulum under their tongue and lip, the problem is when it becomes restricted and function of the tongue or lip is impaired.
Often times we will see these symptoms in the feeding parent:
Painful Nursing/ poor latch
Cracked, creased ,flattened nipples
Low milk supply
Plugged ducts, reoccurring mastitis
The need to use a nipple shield
Infant symptoms may include:
Poor or shallow latch
Long feedings often falling asleep at the breast
Slips on and off nipple during feeds
Reflux and or colic symptoms
Clicking noises while feeding
Poor weight gain
Chewing or gumming the nipple
Inability to flange to the lips on the breast or bottle
Milk dribbling out of the mouth when feeding
There are other symptoms not necessarily associated with feeding that we attribute to tongue and lip ties as well. These include:
Often an IBCLC (International Board Lactation Consultant) will notice the restricted frenulum/ function.
Well, oral anatomy is on our radar. If you hare having feeding issues, an oral assessment with the infant should be part of your consultation with an IBCLC. We examine the tissue under the lip and tongue as well as observe a feed to assess function. We may even use a scoring tool looking to see how the tongue moves, cups, suckles and elevates.
My IBCLC thinks my baby may have a tongue or lip tie, now what?
Your IBCLC should be able to give you some referrals for 1. Bodywork and 2. A diagnosis and revision.
Did you know that a Lactation Consultant cannot diagnose oral restriction? This needs to be done by a Doctor. Most commonly a Pediatric Dentist or ENT.
What is Bodywork?
Bodywork is extremely important in regards to assisting the restriction from releasing. According to Bodyworkers of Ankyloglossia:
"Practitioners use hands-on assessment to locate areas of decreased mobility, tightness or restriction and gently help to mobilize the area using gentle experienced touch. Bodywork helps baby with body awareness and maximizes baby’s access to postural reflexes and natural movement inclinations through the nervous system."
For optimal results bodywork should be done before and after a revision. I am so lucky to work closely with a Chiropractor and a Licsenced Massage Therapist who both specialize in infants and Cranial Sacral Therapy. Your IBCLC should make a referral for bodywork as soon as possible so you can get a session in before the revision.
Here is a list of the Types of Providers regarding Bodywork someone could work with regarding oral restriction.
Your IBCLC will refer you to a specialist (Pediatric Dentist or ENT,) that will diagnose and release the oral restriction. Meet with the provider and make sure they have experience, you feel comfortable and they have a post-revision care policy in place (stretches/lifts to do at home and a referral resource list; any good provider will know local resources! Sending you home with an uncomfortable baby and no after care is a red flag.)
A frenectomy uses a laser or scissors to remove the tissue. There is no general anesthesia needed (for more on why this is, click here.)The baby is typically gently swaddled, the frenulum may be numbed, a groove director tool can be used to lift the tongue and then the revision is done by laser or scissors.The procedure is very quick, complications are rare and baby will have the opportunity to breastfeed or bottle feed right away.
The ideal provider also has an IBCLC and a Bodyworker on staff. This team approach addresses the whole baby and leaves you with a complete care plan for the best results post-release. An IBCLC will continue to work on latch and overall feeding goals, even if you are bottle feeding your infant may need suck training to learn how to reuse and strengthen his/her tongue. The Bodyworker will help improve tongue movements, jaw and neck tension and over all oral function.
After the revision your provider will send you home with some stretches to do. These are very important to avoid reattachment because oral wounds heal quickly and cells like to migrate and heal together. Each provider has different goals in mind for these stretches as well as medicinal and comfort management recommendations. You will also need ongoing follow-up with lactation and bodywork once or multiple times depending on your situation after a revision.
It is also helpful to know some non-pharmalogical options for pain management. Babies are typically the fussiest around day 3 and 4 after the release. Lots of skin to skin, on demand feeding and baby wearing are helpful to calm baby and parent. Infant massage, co-bathing and music therapy are also soothing for baby.
Is A Frenectomy Our Only Option?
The frenulum does not get more elastic over time. Some parents like to work with bodywork and do a "wait and see" approach. This is great if your IBCLC and your diagnosing provider give you a borderline diagnosis. Bodywork can get into the surrounding tissues and muscles and relieve some tension around the frenulum but the frenulum itself can never stretch out or get more flexible. You may see after a few sessions with your bodyworker that things are not improving and it is time for a revision.
Sometimes, even babies with extreme Ankyloglossia will not have many symptoms and have adapted to the anatomy they were born with. They may nurse great, gain weight fine and be content little bundles of joy. However, there are other concerns with untreated oral restriction such as, dental/orthodontic issues, potential airway and oral facial issues, speech concerns, eating and swallowing issues, social/emotional concerns as well as other concerns leading into adulthood.
Only you and your partner know what approach you will take. I encourage all my clients to do their own research and whatever decision they make I will be available to help them reach their feeding goals.
In the past few years there has been more research on this topic and I see the black cloud being lifted. I love that more parents are becoming more empowered to do their own research and find answers in their community. I love that there are more resources for families and collaboration between providers. More awareness means a better outcome for families!
If you are local to Eastern North Carolina and need to connect with Tongue Tie Resources please click here.