Ties - Part I, assessment and planning

frenotomyoral evaluationtongue tieties
Written By Leslie Kowalski
 

It takes a village to help a baby with ties

TL/DR
Short, and easy to read book - Fit to Be Tied - a Visual Reference for Parents
Follow Bobby Ghaheri on Instagram or read his blog
Article "Tongue-tie and Tethered Oral Tissues” - also has pictures of lip, cheek and tongue ties.
Overview of research on ties (Instagram video)
Follow Tongue Tied Experts on Instagram or YouTube


First - I’ve written a narrative about ties and oral/body tension. If you have a few minutes - bear with me and continue reading. If you’d like to skip the next section and go straight to articles, podcasts, videos, etc (I won’t be offended!) click this link to go to the resources below.

Overview

As information about ties becomes more well-known, many families ask if their baby has ties. Ties are tight connective tissues (called a frenulum, or frenum) in the mouth - they can be under the tongue (tongue tie), lips (lip ties), or cheeks (buccal ties). Ties cause oral tension, and make it difficult for a baby to feed effectively (and can cause other issues later in life). I think of feeding difficulties as an “early warning system” - if a baby can not use their oral motions properly to nurse or bottle feed effectively, there is a higher chance that other problem may occur later in life.

The first step when a baby is having feeding difficulties is a full functional evaluation (note - this post is not a substitute for that evaluation!). An IBCLC (International Board Certified Lactation Consultant) or SLP (Speech Language Pathologist) with extensive oral/body tension training are the best practitioners for this evaluation - which is a thorough assessment of:

  • Baby’s latch to breast and/or bottle

  • How the baby processes suckling and swallowing (breast or bottle)

  • Baby’s oral and body range of motion, muscle tone, symmetry

  • How this affects your experience - pain, milk intake, challenges with milk supply, how often to pump and bottle feed (and balancing it all!), baby’s comfort during and after feedings, and so much more!

Does my baby have Ties?

Babies with ties (or oral/body tension) have a variety of symptoms. And, their parents are often working overtime to keep the baby satisfied and gaining weight, to ease their tummy upsets, to maintain their milk supply, and deal with many other issues.

Symptoms of ties may include any of the following:

  • a painful/tight latch

  • or the opposite - a latch that feels too light (breast or bottle always falling out out baby’s mouth, or milk is leaking/spilling)

  • breast/nipple damage

  • frequent plugged ducts/mastitis (from poor milk “removal”)

  • endless nursing sessions that don’t satisfy the baby

  • fatigue or constantly falling asleep at the while feeding (breast or bottle)

  • clicking, gulping, sputtering or choking (breast or bottle)

  • reflux-like symptoms (air intake from a poor seal around breast or bottle)

  • baby cannot hold a pacifier

  • baby refuses bottles

  • lip blisters

  • a white tongue (it’s almost never thrush!)

  • tense/asymmetric body or head positions

  • asymmetric head shape, or cranial molding from birth that never resolves

  • snoring/airway issues/open mouth breathing

  • general fussiness, trouble sleeping

  • and so much more!

Sometimes babies are gaining and taking in milk - but may still have oral dysfunction. For example if a parent has strong milk flow, or are using a fast-flowing bottle nipple, the baby may still easily get milk. In this case it seems like all is well - but commonly milk supply will start to decline (from less-effective feeding), and then feeding issues become worse because the baby has to work harder for the milk. The same thing can occur with bottle feeding - the baby may start to get fussier and fussier, and/or start to reject bottles.

A band of resistance can fatigue a baby!

A tie is like a resistance band and causes fatigue!

Some babies have a good latch (or bottle feeding) for a few minutes but then start to narrow, chomp, fall asleep, etc. Ties and oral tension are like doing exercise with a resistance band - you start off easily, but then get tired from the resistance. When their tongues get tired, babies will start to use the wrong muscles - compensating with their lips, cheeks, and jaws. This often causes pain, air intake (breast or bottle), lip blisters, fussiness, and so many other issues.

But sometimes oral tension is not from ties - but from many other issues - including but not limited to: tight/asymmetric muscles or connective tissues, post-birth head re-molding, “recovery” from vacuum delivery or cords wrapped around their neck, from long pushing phases in labor, oral motion dysfunction, immature nervous system, and much more. Because of this, the topic of oral tension is very complex!

I tell all families that all babies are tight at first - the uterus is a tight place and birth is a bumpy ride (especially when birth interventions have been used). In the early weeks all babies need to unwind from pregnancy and birth - I call this “de-uterizataion”

This means that when a baby has oral/body tension, and feeding difficulties - there’s a “which came first, the chicken or the egg” scenario: are tight muscles (anywhere near the mouth, face, or neck) causing the muscles under and around the tongue, lips and cheeks to appear/feel tight or asymmetric and the head/body posture/shape to lean more one way? Or, are tight connective tissues (ties) under the tongue, lip or cheeks pulling on muscles in the face, neck/shoulders, head, and rest of the body?

Either scenario makes it harder for a baby to feed effectively and because the whole body is connected, we want to tease out if it might be one/both (ties vs tight muscles), or if the baby just needs time, practice, and “unwinding” to feed well. This is where bodywork and oral exercises come in (click those links to see info that I’ve written on those topics)

What if I suspect my baby has ties or tight oral/body tissues?

When frenulum are truly tight and causing functional issues - that is the definition of a tie. But other bodily forces cause trouble on their own - mimicking a tie, or making an existing tie even worse. Because of this, my first recommendations is usually time, practicing feeding skills (breast or bottle), oral exercises and bodywork (exercises and massage to help loosen up tight/asymmetric muscles). There are many ideas you can do home, and there are many professionals that can help - many in NJ and PA are listed here.

If muscular/body tension, asymmetry or nervous system function are the root problem, then bodywork and oral exercises should improve feeding and oral/body postures. If there are ties along with the muscular tension, then relieving the muscular tension and aiding overall oral range of motion is still the preferred first choice - because bodywork will “pre-loosen” the baby - aiding in the diagnosis, tie-release procedure, healing/re-learning after the procedure.

For this reason it’s important to not rush to tie release - most babies (and their parents!) need some preparation prior to a release - we call this “optimal timing of release”. This gives you time to prepare the baby - and you (as the person who needs to help the baby) for the whole process.

An IBCLC can not “officially” diagnose a tie (we are also not allowed to tell you that you have a broken leg even if a bone is clearly sticking out!). But, a tie-savvy IBCLC has extensive experience in assessing oral/body function, determining the more likely cause of your feeding issues, aiding the baby’s pre/post release oral and body exercises, and guide your next steps.

When it becomes clear that the baby needs an evaluation to rule in/out ties, and perhaps have the procedure to release them - I have a very specific list of doctors that I refer to. There are too many doctors dismiss ties, or call them “small” or “mild” (there is no such thing), or say that it’s fine because the baby is gaining (which ignores that they may have oral dysfunction and are only compensating to gain weight). On the opposite end there are too many doctors who will release any frenulum (even ones that may not be ties but just needed time and oral/body exercises to function well). And, especially unfortunately - too many that do a poor procedure. The people on my list are very highly vetted from my and my collegues’ experiences. But, again it is crucial that you have a functional evaluation before jumping to any procedures. This page, and also my Ties, Part II page, discuss why.

But, before you go on to Ties, Part II - here are resources to help you learn more about ties and oral/body tension.

I have broken the info into different categories - support groups, articles, videos, books, podcasts, Instagram pages. Think of this as your “library” - pick your favorite learning style to start and choose a few to start. If you want more, come back. My top choices have *** next to them

  • *** Facebook Tongue Tie groups

    • NY and NJ Tongue Tie Support Group

    • There are groups for most states/countries too - search for your area and/or join the Tongue Tie Babies Support Group to connect with people all over the world, and help find a specific group near you.

    • These groups are very informative and supportive - but please remember that ties, or any kind of oral tension/dysfunction, can not be properly evaluated through a picture or video! Only a thorough functional evaluation (see above) can truly determine the source of your issues.

  • Books

    • *** “Tongue Tied” - by Richard Baxter, DMD and a multi-disciplinary team (IBCLC, SLPs, Chiropractor, OT, Dietitian). This excellent (and easy to read) book covers ties through all stages of life - babies through adults - breastfeeding, bottle feeding, eating solid foods, dental issues, speech, sleep issues, and so much more.

    • *** “Fit to Be Tied - a Visual Reference for Parents” - by Renee Beebe, MeD, IBCLC, Short and thorough book book with many pictures for visual reference.

    • “SOS 4 TOTs” - by Lawrence Kotlow, DDS - how tongue/lip ties affect breastfeeding, speech, dental development and pediatric health in general.

    The next books are for adults considering their own oral health and possible ties

  • Instagram Pages

    • @drghaheri

    • @tonguetiebabies

    • @tonguetieexperts

    • @tummytimemethod

    • @teamtonguetie

    • @brooklynmyo

    • @lactationsolutionsofprinceton (that’s my page! I follow and repost many pages that relate to ties)

Leslie Kowalski https://www.lactationsolutionsofprinceton.com
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Ties - Part II, oral evaluation, frenotomy and after.
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At-Breast/Chest Supplementing