I was a first time mom and my baby girl latched for the first time after an uneventful delivery but I knew something was wrong. All of the physical therapy red flags were running through my head. I asked for a lactation consultant in the delivery room, but the staff insisted I wait until I was comfortable in my room before they would send one. By the time a consultant came my nipples were already raw and bleeding. She assured me everything was going well. With continued doubt I ordered another consultation later in the day. Again, the new LC assured me everything looked great. Fast forward four weeks later when I would close my eyes and grit my teeth to feed my always hungry child with tears in my eyes. As a last resort I called a third lactation consultant. After a thorough evaluation, it was concluded that my daughter had a severe lip and tongue tie. Through a swift turn of events, my daughter got her tongue and lip released the very same day. She then received many forms of follow-up treatment and her feeding and breathing improved dramatically. She has been a different child since.
What is a tongue tie/lip tie?
Tethered lip and tongue tissues happen when the frenulum (string that connects the lip to the gum and tongue to the floor of the mouth) are either tight, short, thick, or a combination of the three. Tongue ties are rated on a scale of 1-4. A level one tie would be anterior or at the front of the tongue and grade four being the most posterior or deep under the tongue. The lip tie is also graded on a scale of 1-4. A grade one would be little attachment to the gum with a good amount of lip movement progressing to grade four in which the frenulum attaches to the hard palate and lip movement is restricted.
How do tongue and lip ties affect the breastfeeding relationship?
In short, the tongue is supposed to cup the nipple, bring it to the palate, pull the nipple along the palate to the back of the throat, and use a wave like motion to pull the milk out. When the tongue is tethered at any point along the base it cannot lift efficiently to cup the nipple and squeeze it to the palate. This can mean that the tongue consistently drops off of the nipple which breaks the vacuum seal and makes a clicking sound. This can also mean that the nipple never reaches the palate which can affect many structures in the mouth.
The lip plays an equal role in the breastfeeding equation. The entire lip should be free to flange and rest gently on the areola (this includes the lip frenulum and a side area of the upper lip called the buccal or cheek section). When tethered down, the baby will clamp onto the breast using the lips, causing blisters on the lips. The vacuum seal will be broken and air often leak in because the lip cannot attach properly.
Due to the need for compensatory strategies, babies with tongue and lip ties often become fatigued quickly, burning more calories, are not able to drain the breast effectively, and therefore nurse more often. Compensatory strategies from tongue and lip ties also can affect the mother by clogging her ducts, cracking the nipples, blistering the nipples, and can cause engorgement or mastitis.
Other Issues Associated
Feeding Difficulties: Babies who have tongue ties often use a tongue thrust to move solids or liquids. Rather than pulling food and liquids back with peristalsis they push the food out of the mouth using a thrusting motion due to the tongue being humped in the back of the throat. The child’s gag reflex will often be very sensitive and different textures will make the child gag. Due to a sensitive reflex, any food that enters the mouth may make the child gag. In addition, children need tongue mobility in order to move a bolus of food around the mouth and to the back of the throat. Tongue ties limit the mobility of the tongue and children can have a harder time moving food around the mouth. Food may protrude from the mouth or get stuck in the teeth and gums easier. In addition, a baby may drool easier or an older child may hold the mouth closed tighter in order to keep the saliva in.
Sleep Apnea: A high and narrow palate can decrease the amount of space (airway) in a child. In addition, the tethered tongue humps in the back of the the throat closing the space as well. These two issues block a child’s airway, especially when lying on the back. This may lead to sleep apnea symptoms.
Reflux: When a baby doesn't have a closed seal/vacuum on the breast whether that’s from a lip tie or tongue tie, air will be swallowed along with the milk. When air is swallowed it creates gas bombs in the stomach. When a baby burps or attempts to burp, milk can come up with the gas. This presents as reflux. The correct term for this is aerophagic reflux. It is NOT GERD
Orthodontics: The tongue strokes the palate in order to release hormones into the body. When the tongue can't do the job, a child will still crave the release of the hormones, which they may achieve by thumb sucking or pacifier dependency. These cause the palate to to become high & narrow, creating the need for orthodontics later in life.
Speech: Children with tongue ties may develop speech difficulties. In order to compensate for the lack of mobility in the tongue, a child may keep the mouth closed to be able to navigate the geography of the mouth. Children cannot make clear sounds without complete movement of the tongue. It may also cause other speech issues such as lisps. An untreated lip tie may cause the two front teeth to split, which may also cause speech difficulties.
Posture: A tethered tongue will pull on the hyoid bone, which is the free floating bone under the chin. If the hyoid gets pulled up into the jaw and the muscles spasm around it, the child can adapt a forward head posture.
Treatment of Tethered Oral Tissues
Dentists, ENT’s, and Oral Surgeons may be versed in the treatment of tongue and lip ties. Some professionals may choose to snip the tissue using specialized scissors that look like long tweezers. More recently, many professionals have been trained to use a laser to achieve deeper and more effective releases. A topical numbing cream is applied to the area. The baby is placed in a swaddle to keep the hands from grabbing the equipment and an assistant is used to keep the baby still as to keep the laser on target. The procedure only takes a few minutes to complete. After the procedure the mother is encouraged to nurse the baby in order to soothe the baby and also receive the benefits of breast milk to a wound. The latch should immediately feel different though the baby can often be confused since the release causes different mobility in the tongue and the baby will now need to relearn a new motor pattern.
The mother will be sent home with a wound care protocol. This will allow the wound to heal but not reattach to the gum or floor of the mouth.
When babies cannot feed effectively, the nervous system becomes overly aroused (fight or flight). Seeing a body worker or therapist who in trained to work with these babies can bring the aroused state back to normal. This can help babies who appear agitated or colicky become more regulated and sleep better.
During the delivery process, the bones of the skull squeeze together in order to fit through the birth canal. Sometimes the cranial bones can overlap each other. The malpositioned bones can cause oral and facial restrictions. A trained body worker can release those bones to move freely and be positioned correctly. When bones are positioned correctly, the muscles attached to the bones will be in a relaxed state rather than pulled taught on one side or another.
Babies who have gone through releases will also need to re-learn to suck/swallow effectively. The therapists work with the baby and teach the mother exercises in order to improve the suck swallow pattern. It is important to follow up with the lactation consultant to make sure the latch is now efficient and that the baby is transferring the appropriate amount of milk.
Choosing Not to Release The Tethered Oral Tissues
Some parents choose not to release the tongue and/or lip. This is a personal decision which cannot be taken lightly. If the parents decide not to release the ties it is still recommended to see a body worker. The therapist can still bring the body down to a relaxed state. In addition, slight movement in the cranial bones can relax some of the oral and facial muscles, improving breastfeeding, eating, and oral motor skills. Children who do not have the ties released may require orthodontic assistance or a breathing apparatus later in life but can continue to be functional in day to day life. There is a risk of infection along with any surgical procedure though the risk is extremely small.
The topic of tethered oral tissues is multifaceted and complex, and sometimes controversial . There are many areas of life that can be affected just from having these tethers, and the decision to release the ties is personal and difficult. It is important to weigh the risks and benefits of the procedure, and to talk to a professional who has the proper training and experience. More importantly it is important to think about how and if a release will affect the personal relationship between you and your child.
Elizabeth Morel is the owner of Little Movers PT, Physical Therapy for mom and baby. She provides innovative hypopressive training for core and pelvic floor restoration. She also provides pediatric physical therapy and craniosacral therapy for babies with a specialty of breastfeeding support. You can find her at littlemoverspt.com , Facebook Little Movers PT and instagram @littlemoverspt