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 (see a list of articles from the blog below)
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

Ties are tight connective tissues (called a frenulum, or frenum) that 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 (breast and bottle). 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 other issues can occur later in life, including aspects of oral-facial development, which can impact speech, eating solids, airway health and more.

The first step when a baby has 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 training in oral/body tension 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) can have a variety of symptoms - some are more obvious than others!

  • painful/tight latch causing breast nipple/damage

    • or the opposite - latch feels light (breast or bottle always falls out out baby’s mouth, milk leaks/spills)

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

  • endless nursing sessions that don’t satisfy the baby

  • fatigue or falling asleep while feeding (breast or bottle)

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

  • fussiness, “colic”, and reflux-like symptoms (air intake from a poor seal around breast or bottle, see reflux-related research article below)

  • baby can’t hold pacifier

  • baby refuses bottles

  • lip blisters

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

  • tension and/or asymmetry in body and head posture

  • asymmetry in head shape (or head molding from birth that never resolves)

  • open mouth breathing

  • snoring, poor sleep

  • and so much more!

Parents often work overtime to keep the baby satisfied, gain weight, ease tummy upsets, or maintain their milk supply and breast health. Sometimes babies are gaining and taking in milk - but there can still be oral dysfunction. For example for a parent has strong milk flow, or a baby taking a fast-flowing bottle nipple - the baby may still easily get milk. Sometimes it seems like all is well at first - but if feeding is less effective, milk supply will often decline - and then feeding issues become worse as baby has to work harder and harder for the milk. The same thing can occur with bottle feeding - the baby may start to get fussier and fussier if they are having trouble coordinating the motions needed for the feeding, and may even 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 feed well) 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 after some repetitions. When baby’s tongues fatigue, they start to use the wrong muscles - and compensate with their lips, cheeks, and jaws. This often causes pain, air intake, lip blisters, fussiness, and more.

Sometimes oral tension is not from ties - but from other issues such as tight/asymmetric muscles or connective tissues from vacuum delivery, an umbilical cord wrapped around baby’s neck, long pushing phases in labor, or long NICU stays or other post-birth interventions. The uterus is a tight place and birth and post-birth interventions can be a bumpy ride! So, it’s very common for babies to start off tight or asymmetric.

In the early weeks all babies need to unwind from pregnancy and birth - I call this process “de-uterizataion”.

There’s a “which came first, the chicken or the egg” scenario: are tight/asymmetric muscles in the body causing tension under and around the tongue, lips and cheeks? 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?

Oral issues can also occur from oral-motor dysfunction, an immature nervous system, and more. So, taking all of this together, the topic of oral tension and oral function is very complex. Our goal is to determine if the baby may have ties, tight/asymmetric muscles, just need time, practice, exercises and “unwinding” to feed well, or if there is more going on that requires other referrals. This is where bodywork and oral exercises come in.

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 again, my first recommendations is usually time, practicing feeding skills (breast or bottle), and home-based oral and body exercises (linked just above) to help improve tight/asymmetric muscles and feeding skills. Sometimes professional bodywork is an important addition.

If muscular/body tension, asymmetry, or oral/body function are the root issues - then bodywork and oral exercises should improve feeding and oral/body posture. If there are ties in addition to muscular tension, then relieving that tension and aiding overall oral range of motion is still the preferred first choice - because these actions will “pre-loosen” the baby - aiding in the diagnosis, tie-release procedure, healing/re-learning after the procedure, also familiarize you with your baby’s movements, and how they are changing over time.

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 yourself - 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 likely cause of your feeding issues, aiding the baby’s pre/post release exercises, and guiding your whole journey.

When it’s clear that a 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” - Richard Baxter, DMD and multi-disciplinary team (IBCLC, SLPs, Chiropractor, OT, Dietitian). An excellent (and easy to read) book covering ties through all stages of life.

    • *** “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.

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

  • Instagram Pages

    • @drghaheri

    • @tonguetiebabies

    • @tonguetieexperts

    • @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