Oral Ties: Symptoms, Diagnosis, Treatment

Oral ties, aka "tethered oral tissue" or "TOTs", include overly restrictive bands of tissue that connect the cheek, tongue, and/or lip to the mouth. If these tissues are too tight, short, or thick, they can restrict movement and impact feeding, speech, sleep, breathing, and more.

The most common oral tie that impacts breastfeeding is a tongue tie, where the tongue does not have full range of motion. To feed effectively, the tongue needs to be able to elevate, extend, and lateralize. The tongue's ability to elevate is particularly important while breastfeeding as the tongue uses a wavelike motion where the tongue elevates then lowers, this movement creates a negative vacuum pressure which removes milk from the breast. Tongue ties can appear closer to the tip of the tongue (aka anterior tongue tie) or further back and even in under the mucosa of the floor of the mouth (aka posterior tongue tie). The most important thing to know about a tongue tie is that it is diagnosed based on function, not appearance. As an IBCLC, it is not within my scope to diagnose an IBCLC, but I am able to evaluate tongue function and range of motion and refer out as needed. In some cases, baby has a closely attached frenulum but the baby feeds effectively and has no other significant symptoms (described below). In this case, this is not considered a tongue tie as baby has full range of motion to feed effectively. There is possibility that the frenulum could cause issues in the future, but it is not my recommendation to surgically alter a frenulum if it is not causing issues in the present.

Common symptoms related to oral ties include:

• Poor or slow weight gain

• Pain during the feeding

• Nipple damage

• Creased/lipstick shaped/flattened nipple after feeding

• Clicking and smacking throughout feeding

• Two-tone lips or lip blisters

• Excessive spit up and gas

• Frequently unlatching and slipping off the nipple

• Overactive gag reflex

• Milk residue on tongue

• High palate

• Unable to hold a pacifier

• Low milk supply

• Sleepy nursing that does not improve as infant gets older

• Very frequent short feeds

• Slow weight gain

In isolation, these symptoms do not indicate that your baby has a tongue tie but your care team can help you look at the whole picture to see if oral ties are related to the feeding challenges and co-create a plan of care. There are some cases where babies feed and gain weight well in the first few weeks when the parent's milk supply is robust but then falter in growth as the supply decreases due to poor milk removal and baby's mouth gets larger so the tongue ROM becomes increasingly insufficient. Susan Howard, IBCLC with Arlington Lactation, refers to this as "watchful waiting", when there are signs of oral restrictions but at the current time it is not causing feeding challenges. Susan recommends more frequent weight checks for these infants to ensure that weight gain does not decline as compensatory patterns are no longer sustainable.

If an oral tie is identified, the typical treatment is to release the tethered tissue with a laser or scissor (called a frenotomy or frenectomy). This is a short (<5 min) procedure done usually by an ENT or dentist. Some families choose to release a tie as soon as possible, while others prefer to avoid changing their baby's anatomy. In most cases, I recommend pursuing oral therapy and bodywork prior to, and possible in place of, pursuing a release to see if we can achieve symptom resolution by reducing oral tension and improving the compensatory patterns, such as chomping, that baby has acquired to be able to feed. A true tongue tie will not stretch on its own, but in some cases if oral tension is resolved, the tongue ROM significantly improves without release. Options for bodywork and oral therapy include:

• Speech-language pathologist (SLP) - Focus on improving oral motor skills involved in speech, swallowing, and feeding

• Occupational therapist - Focus on reflex integration and sensory processing

• Physical therapist - Focus on gross motor development and milestones

• Craniosacral therapist - Focus on calming the nervous system through aligning connective tissue

• Chiropractor - Focus on addressing misalignments in the spine

Each of these providers have a slightly different approach and should be selected based on accessibility, parent preference, and targeted to underlying roots of baby's challenges.

If symptom resolution is not achieved with a combination of positional strategies, optimizing milk supply, oral therapy, and/or bodywork, a release may be indicated. It is important to choose a provider who is skilled in TOTs and reputable in providing safe and thorough frenectomies. I can provide you with a variety of options for preferred providers and will coordinate with them to ensure they are aware of the feeding challenges and reason for pursuing release.

At Bridges Lactation, we understand how stressful it can be to be told that something is "wrong" with your baby and may need a surgical procedure to fix it. Please know that a release is not a medical emergency and if you are feeling stressed or pressured by any member of your care team to release now, know that you know your baby best and we will work together to create a care plan that is reasonable for both you and your baby. Schedule a consultation today to get support.