Oral ties

One of the most common breastfeeding problems that can make nursing your baby much more difficult is a tongue and/or lip tie. It seems that this is an issue that is happening more often than it ever did in the past. It could be partly that we are getting better at diagnosing these ties, but there is also the theory that the high doses of folic acid that moms take in their prenatal vitamins can be contributing to it. While folate is beneficial in preventing problems like spina bifida because it builds connective tissue (and frenulums are connective tissue) this could be contributing to the increase in oral ties. There is also a genetic component, so if either or both parents have a tongue tie, the baby is more likely to as well. I certainly have seen many babies with ties whose siblings have had them too.

So what exactly is a tongue or lip tie? The frenulum is the little stretchy piece of tissue that connects the upper lip to the upper gumline (called the labial frenulum), and the lingual frenulum is the connective tissue under the tongue. We all have frenulums and they are not problematic unless they are thick, short and/or tight. An anterior tongue tie is very noticeable because it extends to the tip of the tongue, often causing a heart-shaped appearance to the tongue. A baby can also have a posterior tongue tie, which is further back towards the middle of the underside of the tongue where it is more difficult to see without a proper examination. It takes an experienced practitioner to identify a posterior tongue tie. The lip tie will extend down to the bottom of the upper gumline, often causing a little notch in the gums. If you try to flange the baby’s upper lip with your fingers, you can see pockets on either side of the frenulum and the lip will resist flaring up. Even if these ties are evident, it is not always a problem because it is all about function, not appearance. I have seen some babies with visible oral ties who nurse beautifully with no issues, and have seen some kids whose ties look less severe but who have many problems because of them.

What kinds of problems do oral ties cause? The tongue is an integral part of many oral functions.For breastfeeding, a normal tongue moves in a wave-like motion which helps to scoop the nipple far enough back into the mouth to effectively suckle. If the tongue is tethered, it instead moves in a piston-like motion, preventing the baby from drawing the nipple far enough back into the mouth. This causes nipple pain and damage for the mother, but also can result in ineffective milk transfer. Babies will often struggle to gain weight due to an inefficient suck, and this becomes a vicious cycle when mom’s milk production suffers because the baby is not suckling effectively. This then effects the baby’s growth even further. Babies often swallow air due to their abnormal suck (called “aerophagia”) which can lead to a gassy, fussy, spitty baby. Tongue ties can also cause reflux, sleep apnea, difficulty swallowing (especially solid foods), and later on, speech issues. Because everything in the body is connected, tethered oral tissue can affect jaw and facial development and orthodontic problems. Lip ties can cause decay on the upper teeth because food gets trapped in the little pockets on either side of the frenulum. With breastfeeding, a lip tie can lead to a baby tiring at the breast because they have to hang on tightly with their upper lip in order to sustain their hold on the breast. Normally, the lip flanges to form a seal around the breast, but if the lip tie won’t allow for that, the baby has to struggle to maintain suction. They often won’t feed for an adequate amount of time because they tire before they finish. This can also result in poor weight gain and a reduced milk supply for mom. It can also lead to a baby who wants to feed constantly, because they never sustain a nutritive suck long enough to be satiated.

What to do if you think your baby has a tongue and lip tie? (they usually go together) It is important to seek an appointment with a lactation consultant who is experienced in working with babies with oral ties. A thorough feeding assessment is vital. You can’t look in a baby’s mouth and determine if their oral anatomy is a problem without first assessing function. If you think your baby is experiencing feeding issues for any reason, it is necessary to have a complete feeding observed and a full oral examination performed. If it appears that oral ties are present and a cause of feeding difficulties, then a consult with a pediatric dentist who is experienced with treating babies with tongue and lip ties is warranted. It is also important for the baby to receive bodywork with a baby chiropractor and/or a cranial-sacral therapist. This will help to loosen the jaw, neck and facial muscle restriction that goes along with tongue ties. As the baby is developing in the womb, these ties restrict all the muscles that are connected.

If the pediatric dentist deems the procedure necessary, a laser frenotomy will be performed. It is a quick procedure with no sedation necessary for an infant- just a tight swaddle and a topical numbing agent. Babies are sometimes fussy the first day or two as their little mouths are sore, but they bounce back quickly and will often start to feed more effectively relatively quickly. Oral exercise and “stretches” are necessary to help the baby begin to move their tongue normally and to prevent reattachment. This warrants another visit to the lactation consultant and continued bodywork. Though no mother wants to put her baby through an uncomfortable procedure, the long term benefits surely outweigh the very temporary discomfort that the baby experiences. I am always somewhat surprised when parents are hesitant to have the frenotomy performed, when they have had their baby circumcised! Circumcision is 1000 times more invasive and painful for the baby, and is simply a cosmetic procedure with no medical benefit whatsoever.

So if you suspect that your baby is having feeding problems that might be related to their oral anatomy, start with a feeding assessment with an experienced lactation consultant. A cursory peek into the mouth is nowhere near an adequate judgement, and waiting many months until the problems become insurmountable is regrettable when early intervention can avoid these issues. It is definitely a “fixable” problem with proper guidance and care.