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Ties - Part I, assessment and planning

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Table of Contents for all blog posts

It takes a village to help a baby with ties

TL/DR
Get this easy to read but also very thorough book (Fit to Be Tied - a Visual Reference for Parents)
Join the NY and NJ tongue tie Facebook group
Follow Bobby Ghaheri on Instagram
Follow Tongue Tied Experts on Instagram or YouTube
Skip my overview (next) to get to the other resources below (articles, podcasts, videos, books, etc)

Overview

As information about ties becomes more well-known, there are many families asking 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 also cause other issues later in life). I often think of feeding difficulties as an “early warning system”. If a baby can not use their oral motions properly to nurse or bottle feed (and this is so much more than just being able to physically get the liquid down and gain weight - more on that below) - then the chance that other issues may occur later in life is higher.

The first step in “unwinding” this process 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 excellent practitioners to work with for this evaluation - which is a thorough assessment of:

  • Baby’s latch to breast and/or bottle

  • How the baby processes suckling-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 much more!

Many people join local Tongue Tie Facebook groups (see below for some) - and these can be great places to get support and to find suggestions for IBCLCs, SLPs, PTs, (etc) in your area. Keep in mind, though, that many people will share pictures of their baby’s mouths on these groups. This can be helpful but it’s so important to know that a tie, or any kind of oral tension/dysfunction, can not be properly evaluated through a picture or video! Only a thorough functional evaluation can truly determine the source of your issues.

As part of the info on this page, I’ve written a lot more about the most up-to-date approach for unraveling the topic of 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 to resources (articles, videos, books, etc) click this link and it will take you to the bottom of this post where I’ve listed them.

Does my baby have Ties?

A baby with ties (or oral/body tension) may have a variety of symptoms. And, parents are often working overtime to keep the baby satisfied and growing, to ease the baby’s tummy upsets, 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 is always falling out out of babies mouth, or milk is leaking/spilling))

  • breast/nipple damage

  • frequent plugged ducts/mastitis

  • 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 (from air intake)

  • baby cannot hold a pacifier

  • baby refuses bottles

  • tense/asymmetric body or head positions

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

  • snoring/airway issues/open mouth breathing

  • lip blisters

  • general fussiness, trouble sleeping

  • and so much more!

(Of course many of these issues occur for reasons other than ties and oral/body tension/asymmetry, but this is a list of very common ones that we see)

Sometimes babies are gaining and taking in milk - but sometimes they may still have oral dysfunction. For example some babies get milk easily from their parent’s fast flow or a fast-flowing bottle nipple. In this case it seems like all is well, but then if milk supply starts to decline (which often occurs if baby’s latch is less-effective), then latch/feeding issues become more obvious - because now the baby has to work harder for the milk. And, the same 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 for a few minutes but then start to narrow, chomp, fall asleep (breast or bottle), etc. Ties and oral tension can be like doing exercise with a resistance band - you can start off easily, but then get tired from the resistance. Sometimes babies will start to use the wrong muscles to make up for this fatigue and compensate with their lips, cheeks, jaws (etc) - this can cause latch pain, air intake (breast or bottle), lip blisters, fussiness, and so many other issues.

In the early weeks/months, all babies need to “unwind” or “de-uterize” after pregnancy and birth (the uterus is a tight place and birth is a bumpy ride!). That means that sometimes oral tension is not from ties but from tight/asymmetric muscles or connective tissues, post-birth head molding, oral motion dysfunction, immature nervous system, and much more. Because of this, the topic of oral tension is very complex!

So when a baby has oral/body tension, I think of it as 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 a baby needing some time, practice, and “unwinding”. This is where bodywork and oral exercises come in (click those links to see much more info that I’ve written on both of these topics, and also see more on this next)

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 because other bodily forces can cause trouble on their own, or even make a tie worse - my first recommendations is usually time, practice with 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 - and then we re-check how things are progressing.

If muscular/body tension, asymmetry or nervous system function are the root problem, then bodywork and oral exercises should improve feeding/oral function. If there are ties along with the muscular tension, then relieving the muscular tension first 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, and healing from the procedure. As well as aiding the baby re-learning to use their newly freed tongue after the procedure. For this reason it’s important to not rush to a tongue-tie release - most babies (and their parents!) need some preparation prior to a release - we call this “optimal timing of release” and it gives you time to prepare the baby physically, neurologically, and time to prep you (the person who needs to help the baby) for this process too!

An IBCLC highly trained in ties, and oral/body tension/asymmetry 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 sticking out!). But, a tie-savvy IBCLC has a lot of experience assessing oral function and helping you to determine the more likely cause of your feeding issues, 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 - for that I have a very specific list of doctors that I refer to - there are too many doctors dismiss ties, or call them “small”, or say that it’s fine because the baby is gaining (which ignores that they may have oral dysfunction). On the opposite end there are too many doctors who will release any frenulum (even ones that may not actually be ties). 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 my next blog post - Ties, Part II, discuss why.

But, before you go on to 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. Don’t feel like you need to look at everything here! Think of this a a “library” - pick your learning style to start, and/or choose a few from each category. My top choices have *** next to them

  • *** Facebook Tongue Tie groups - very informative and supportive!

    • NY and NJ Tongue Tie Support Group. There are other area-specific groups on Facebook as well - if you are not from NY or NJ, search for your area.

    • Tongue Tie Support Group - a great group to connect with people all over the world, and as a starting place to help you find a specific group near you.

<—— At breast/chest supplementing ———-—— Ties, Part II ——-->