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Tongue And Lip Ties
Overview and Reference Guide

Tethered Oral Tissues (TOTS aka Tongue-Tie)

COMPREHENSIVE OVERVIEW OF TONGUE AND LIP TIES

We believe education is key to making fully informed decisions about the care of your growing family. The IBCLC's at Milk Diva are ready to equip and navigate families through all the stages of infant feeding and oral habilitation.

Milk Diva's Tongue-Tie Quick Reference

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Releasing the boat from the dock alone, cannot make it sail.

-Autumn R. Henning SLP, COM, IBCLC

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BREASTFEEDING SYMPTOMS

Tongue-ties or oral restrictions cannot be diagnosed just based on pictures or symptoms alone. A full functional and structural evaluation is required.

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Mother’s Symptoms
  • Painful nursing

  • Creased or flattened nipples

  • Blistered or cut nipples

  • Incomplete breast drainage

  • Plugged ducts or mastitis

  • Inability to nurse without using a nipple shield

  • Decreased milk supply

Baby’s Symptoms
  • Poor latch

  • Poor weight gain

  • Reflux or frequent spitting up

  • Frequent gassiness and fussiness

  • Clicking or smacking noises when eating

  • Dribbling milk out of mouth

  • Frustration when eating

  • Inability to hold a pacifier

  • Prolonged nursing or bottle-feeding sessions

  • Mouth breathing

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OUR LACTATION CONSULTANTS ARE FULLY VACCINATED

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COVID-19 UPDATE:

To ensure your safety and quality of care

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Suck Blister

This not always normal.

Who knew so many of these symptoms could be related to oral restrictions?

PIECES OF THE TOTS PUZZLE

 
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PARENTAL AND PROVIDER EDUCATIONAL VIDEOS

TONGUE & LIP TIES

Unraveling the confusing & conflicting information

Parental Videos

Provider Videos

Tongue-Ties & Babies Presentation for Parents is presented by Dr. Richard Baxter, DMD, MS, of Alabama Tongue-Tie Center, is one of our country's nationally recognized speakers on tongue-ties, instructor of the course Tongue-Tied Academy, and author of the best-selling book Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More.

Dr. Bobby Ghaheri discusses why the mid and posterior part of the tongue is vital to achieve optimal breastfeeding. He also discusses proper post release wound management.

 
 
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COLLABORATIVE CARE

For Optimal Outcomes

One of the biggest misunderstandings about frenectomies is that the actual procedure is all that is needed to “fix” a baby with tongue tie

 

The Board Certified Lactation Consultants (IBCLCs) at Milk Diva believe in an integrative, and collaborative approach to achieve long-term, optimal oral function.

The goal when treating ties is to restore optimal oral function; however, in many cases, in addition to the frenectomy, the parents and the child will need the help of multiple specialists to prepare for the procedure and work with the baby afterward in order to fully achieve their goal fully.

Dentist

Ear, Nose & Throat MD

Oral Surgeon

Craniosacral Therapist (CST)

Pediatric Chiropractor (DC)

Physical Therapist (PT)

Release Provider

Body Worker

Functional
Professional

Lactation  Consultant  (IBCLC)   

Speech Language Pathologist (SLP)

Occupational Therapist  (OT)

Finding the right help is important. Asking the right questions is key.

There are many types of providers that fall under each broad category, but the MOST important quality to look for, no matter which type of provider, is they are specifically trained in the problems and solutions related to ties and oral dysfunction - this means they have taken EXTRA education in these areas.

 

Do not assume these types of providers automatically know about ties and oral dysfunction. ASK if they have had specialized training before booking an appointment. A good place to start is with a specially trained International Board Certified Lactation Consultant (IBCLC), Speech Therapist/ Speech-Language Pathologist (SLP) or Occupational Therapist (OT). Any one of these professionals can identify ties and help find the best bodyworkers and release providers for your baby.

 

How Do I know if my baby has a restricted lip or tongue (TOTs/tongue-tie)?


In the same way a family practice doctor would not be the best provider to identify or diagnose a heart condition, the same is true for identifying and diagnosing oral dysfunction related to tethered oral restrictions. It might be a surprise to you but oral restriction education is not part of the standard curriculum for Lactation Consultants, Dentists, Pediatricians, Occupational Therapists or Speech Language Pathologists. The best way to find out if your baby has TOTs is to have him/her evaluated by a provider who has specialized training in oral restrictions. In order to find out if your baby has an oral restriction, your baby will need: Functional assessment first (usually a specially trained IBCLC, SLP) Structural assessment (usually a specially trained ENT or Dentist)




My Baby Has TOTs, Now What?


Work with your team of providers, to learn what your options are and what are appropriate expectations to have with each option. Take time to consider:

  • Are you able to provide the time to the pre & post operative stretches/tongue lifts, as advised?
  • Will your baby be able to work with a body worker before and after the procedure?
  • Do you have the capability/capacity to make it to appointments with your care team as advised?
  • Are you emotionally well enough to embark on this journey?
  • Do you have the support of someone who can help you during this time
  • Do you have a plan for comfort measures for your baby after the procedure?
    • Discuss with your pediatrician or Dentist
  • Do you understand things will not miraculously improve right away and this may be a slow and steady process?
If there are more than 1 or 2 ‘no’ answer, please discuss an alternative feeding plan with your team.




Will a Release (Frenectomy) Fix My Breastfeeding Issues?


One of the biggest misunderstandings about frenectomies is that the actual procedure is all that is needed to “fix” a baby with tongue tie. The goal when treating oral restrictions is to restore the mouth to optimal oral function. In most cases, in addition to a frenectomy, the help of multiple specialists are required in order to achieve optimal oral function. THE 3 AREAS OF BEFORE AND AFTER PROCEDURE CARE FOR BABIES:

  • Lactation Support, Bodywork, and Oral Motor/Feeding Therapy
Success of a tongue tie release is dependent on addressing ALL THREE AREAS. copyright Autumn Hemming, MS, CCC-SLP, COM, IBCLC image copyright Autumn Hemming MS, CCC-SLP, COM, IBCLC




Collaborative Care - Who Makes Up The Team?


Finding the right help is important. As you can see below, there are many types of providers that fall under each broad category, but the MOST important quality to look for, no matter which type of provider you are searching for, is to make sure that they are educated in the problems related to ties and oral dysfunction - this means they have taken EXTRA education in these areas. Do not assume that these types of providers automatically know about ties and oral dysfunction. Lactation Support Lactation specialists will help with breastfeeding issues, as well as pumping and bottle feeding issues. Bodywork If there are oral restrictions, there are whole body restrictions - bodywork allows for full and symmetrical motion of the head and neck which will improve motion in the jaw and mouth. More info: http://www.ankyloglossiabodyworkers.com/benefits-of-bodywork.html A Release Provider This can be a specially trained Dentist, ENT or Pediatrician. At this present time, Austin, TX has very few providers with specialized training in identifiying and treating all degrees of oral restriction. We highly recommend your baby be treated by a highly specialized provider, to reduce the risk of needing a repeat procedure. Oral Motor/Feeding Therapy Rehabilitating the tongue and other oral muscles is IMPERATIVE to getting the best results. In order to have optimal function, baby must be evaluated and treated by a specialized feeding therapist. The IBCLC's at Milk Diva have been specially trained to provide oral rehabilitation for the breastfeeding dyad. Here is a terrific podcast for a few of our Country's top infant feeding specialists and Occupational Therapists discussing how Tongue-Ties effect the entire body.




What are some of the symptoms and long-term effects of TOTs?


Following may be affected by tongue tie:

  • Breastfeeding
  • Sleep Quality
  • Bottle feeding
  • Airway Function
  • Solid feeding
  • Dental Health and Alignment
  • Speech Attention
  • GI function Sensory
  • Musculoskeletal Health
  • Sinuses/Allergies




Facts about Laser Releases of Tethered Oral Tissues


  • Children do not outgrow TOTs although they will develop a variety of compensating dysfunctional habits
  • A full functional and clinical assessment is necessary in order to make a proper diagnosis of TOTs
  • It is usually best to release as soon as the problem is identified
  • No operating room or general anesthesia needed
  • It is typically best to release both lip and tongue for full function
  • We are not cutting lips or tongues, we are releasing restricted lips and tongues
  • The procedure is safe as long as performed by a properly trained and experienced laser surgeon using all recommended safety precautions
  • There has never been a reported incident of infection
  • The actual “touch time” with the laser is only a few seconds
  • The infant can breastfeed immediately after the release
  • Post-Op lifts are necessary to prevent constriction of the healing site
  • Always follow up with a competent Lactation Consultant specially trained in oral habilitation post frenectomy
When restrictions caused by TOTs are present, there are often other associated fascia restrictions so bodywork is an important part of the rehabilitation process




Why Does My Provider Not Know About Tongue-Ties?


Article from Dr. Baxter, see full article. “Why Does My Provider (Doctor, Dentist, Therapist) Not Know About Tongue-Ties?” MAY 7, 2021 | TONGUE TIE TERMINOLOGY, TONGUE-TIE MYTHS, TONGUE-TIE TIPS We receive some form of this question daily in our office after parents realize their child has a restricted tongue that is causing the family struggles. It hasn’t been identified previously, or they asked their trusted provider and received no information or even advice against having the tongue-tie released. Most of the time, the restricted tongue is less obvious and attaches less than 50% of the way to the tip. Those would be considered “posterior” ties, which some like to say “don’t exist” but in fact can cause the same range of symptoms as a to-the-tip tie. For nursing babies, most of the time the babies and moms reporting the most painful latches (7+, toe-curling pain) are less obvious, posterior ties. And the pain resolves after release. The term posterior is not the best, but it’s what most people call it. It just means it’s not obvious and anterior or attached toward the tip of the tongue. However, we have many come to see us that have an obvious, all the way to the tip attachment, or close to the tip attachment. They asked their provider who said it would “stretch out” or “not be an issue now or in the future.” This thinking comes from a true systemic lack of education on the importance of a restricted tongue in medical, dental, and therapy programs. Your pediatrician, therapist, or dentist is a great person. They have put in countless years of training and dedication to serving families. They just haven’t learned about tongue-ties before, and most of what they now know comes from asking colleagues, or their best guess. In dental school, we had one slide of one lecture showing a Z-plasty advanced technique for removing a tongue-tie, and the take-home message was, “don’t try this at home, just leave it to us oral surgeons.” The patient must be asleep, and the only reason to do this would be if the patient can’t talk well. That’s literally all we had. In residency, we had one article that was almost 10 years old in a stack of 20 other articles we had to discuss that day. And we read through a lot of articles in residency, so the implication was it’s not that important. Medical and therapy programs’ training is similar. Pediatricians have very little education on tongue-ties, most of it outdated, like dental curricula. The leading pediatric textbooks say that a tongue-tie will “spontaneously lengthen” and “rarely interferes with feeding and speech.” (Nelson, 2011) These are the myths that are not supported by evidence, but they are in the textbook, so no one questions them. When they do cite an article as evidence, it’s often an opinion piece from 1963 by a British doctor (Wallace) that says it “may interfere with some speech sounds or playing a wind instrument.” It also says that tongue-tie does not affect speech delay, and this myth persists to this day (and was showed to be in error in our recent article.) But that article also says, “much entertaining nonsense has been written about tongue-tie” and has a dismissive tone throughout the article that unfortunately persists today in the pediatric and ENT world. Organizations now are putting out “consensus papers” that are not actually seeking consensus but rather cherry-picking data that supports their position and not allowing anyone who holds a different opinion to participate in the paper (mainly, people who treat tongue-tie daily instead of once a month or once a year). Those excluded people see the results from the procedure and know it works when performed properly, so the people writing the paper don’t want to have debate or discussion, they just want to dictate “here are our opinions, this is our official policy” but pass it off as “evidence-based research.” Even in my own backyard, at a recent conference for pediatricians in our state, they were taught that tongue-tie rarely causes issues, lip-ties don’t impact breastfeeding, there is no such thing as a posterior tie (just a less obvious restriction), and lasers are dangerous. Here’s a photo to prove it! How do we address all of these issues in our office? With humility and understanding, never bashing other doctors or providers, as I was in that same place too when I first heard about tongue-ties. When a lactation consultant told me our girls have a tongue-tie, I immediately said, “no they don’t” because it wasn’t to the tip. I was a dentist and thought I knew what a tongue-tie was. I didn’t know what I didn’t know. But I was interested enough to research further, have an open mind, and now after treating thousands of patients with the procedure, it can and does make a huge difference when performed properly. To properly release a tongue-tie, you must have a complete evaluation and full history from the parent. A quick look under the tongue with no gloves and only a tongue depressor is what we most commonly hear from patients was the only exam performed on their child. This is not even close to a full exam. The release must be a complete release as well, meaning all of the restricted tissue removed, and a diamond-shaped wound is evident after the release. No muscle is taken, just fascia, down to the genioglossus. Follow-up is critical to see what happened after the release and change your protocol, refine your technique, and troubleshoot issues. Most parents who see us who had a clip or snip before were offered no follow-up visits and told that stretches are unnecessary. Of course, if the patients aren’t brought back for a check, how do they know if stretches are needed or not or if it healed back together or not? Stretches are indeed important, as it’s the same as if you had your ear pierced but didn’t wear the earring. Every pre-teen girl knows you have to wear the earring or else it will close up, but somehow this is lost on many “clipping” the tongue and moving on. All this to say, how can we see change? We are doing all we can to educate providers in our community by writing a book (Tongue-Tied), publishing articles and doing research (our recent paper published in Clinical Pediatrics and another in Compendium), sending letters to our patients’ providers, answering countless emails, and speaking at conferences. More work is clearly still needed, but slowly the tide is turning. We have many pediatricians now referring to us, some after saying “it doesn’t work” but seeing the results in their own patients. Many therapists really see the results because they are working with the families weekly, sometimes for years, and all of a sudden see a massive change, or even a “whoa that was different” response during therapy after a release. Partnering together for the good of our patients, not excluding one another, and supporting each other as providers is the best way forward. We are always looking to help our colleagues in our area learn more about tongue-ties, so if you are interested, send us a message. We are also dedicated to helping providers worldwide (literally) with this procedure, so we have the book Tongue-Tied, online Tongue-Tied Academy, and live course, all with the goal of educating others so they can help countless patients in their community. We have to move on from the outdated recommendations of 1963 before evidenced-based practice and see the results that are available to our patients with tongue restrictions if we provide a proper release and follow-up, and always with a team approach to care. Full Article with images.





Answers to Frequently Asked Tongue-Tie Questions