Tongue Ties and Oral Restrictions

This can be a very controversial issue in the breastfeeding realm right now. There is a lot of good information out there, but we’re still learning so much. Like most things, I think it’s best to look and listen carefully, get second opinions, and pay close attention to your baby and to your intuition.

What Oral Restrictions Are and How They Work

You probably hear most about Tongue Ties, or Ankyloglossia. This is one type of oral restriction. This is where the tissue (frenulum) that connects the underside of the tongue to the bottom of the mouth is short or extra thick or tight.

You might assume that this would make certain things more difficult. It can, depending on the severity of the restriction, the number of restrictions, and other factors. Sometimes people function normally, or they may have a lot of problems related to it, or a problem in just one area. So for example, a tongue tie might not restrict a baby from breastfeeding, but it might affect the way they talk later in life.

There are also frenula that connect your upper and lower lips to your gums, and connect the cheek to the gum. So in addition to tongue-ties, there can be lip-ties and buccal (cheek)-ties. When these frenula are too tight or short, it can cause a restriction in the way the tongue, lips, and mouth move. It can affect breastfeeding, but also can cause difficulties with breathing during sleep, proper palate development, picky eating, dental crowding or spacing, jaw function, neck posture, speech, and mental health issues related to any of these problems.

That all might sound scary, but many cases of oral restriction are never even discovered because it doesn’t cause significant dysfunction. Many people develop and function normally by working around those restrictions.

When Oral Restrictions Cause a Problem With Breastfeeding

Sometimes a tongue-tie that looks severe doesn’t cause any functional problems. That baby might be latching just fine and is happy and gaining plenty of weight. Other times, a less severe tongue-tie can cause big problems for breastfeeding. There are many factors. Most Lactation Consultants (IBCLCs) will do an oral assessment to see if there seems to be a restriction only if you are having problems with breastfeeding or even just as part of a standard consultation. If you are not having problems, this might never come up. A significant oral tie can cause problems such as:

• Pain with breastfeeding: To work around the restriction, a baby may not be able to latch onto the nipple properly, causing a lot of nipple discomfort.
• Deformed nipples: A baby with an oral restriction might have to hold the nipple in a way that causes it to look deformed after breastfeeding. It might look asymmetrical or flattened.
• Latching problems: The baby might have trouble latching on to the breast, showing frustration or exhaustion. This can sometimes lead to the baby rejecting the breast.
• Incomplete breastfeeding: The baby might not be able to completely drain the breast because of a bad latch or exhaustion from having to work extra hard to get milk.
• Too long on the breast: A baby might need to spend a lot more time at the breast to get enough milk, causing discomfort or frustration for the breastfeeding parent.
• Not enough weight gain or weight loss: If your baby has a lot of trouble getting milk from the breast, you might see weight loss or insufficient weight gain.

If you are having any of these issues, seeing an IBCLC is a great first step. They can do a very thorough assessment and help you figure out what is going on. Our team members receive training in using the Hazelbaker Assessment Tool for Lingual Frenulum Function. This tool is not used to diagnose an oral restriction. Instead, they use this as a way to rule out any major restrictions and focus on finding the actual cause of the problem, or to make a referral to another care provider if they do suspect some significant restriction.

Assessment and Treatment Options for Oral Restrictions

There are primary care providers like pediatricians and family practice doctors who can diagnose a tongue-tie or other oral restrictions, but when a referral is needed, there are a couple of professionals who are usually chosen to assess and diagnose an oral tie because of their special training and expertise in this area.

• Pediatric dentists
• Ear, nose and throat specialists (ENT)

Diagnosing is the first step, but then a treatment plan needs to be made. For this, having a team approach is usually helpful. There may be more assessment needed to decide what kind of intervention might be most helpful. A pediatric dentist and an ENT can both diagnose and perform a minor surgery to release the restriction. This is done either with small scissors or a laser. It is a very quick outpatient procedure, and there is some follow-up care needed. However, this procedure is not always necessary, or it might be helpful to have some supplemental therapies in addition to the surgery. Some other providers who might be enlisted to decide on the best treatment plan could include:

• IBCLC: If breastfeeding is being affected by the oral restriction, they may suggest ways to help that do not involve having surgery. Sometimes simple modifications such as adjusting position and latch can be enough to help the baby get over the initial hurdle and things can progress smoothly from there. If you do decide to have the procedure, an IBCLC can then help assess your baby’s feeding after and make suggestions for moving forward.
• Speech-Language Pathologist (SLP): They can assess for any other functional issues that the restriction might be causing such as trouble with speech or swallowing. Knowing this can be helpful when deciding what kind of intervention to do. In some cases, if breastfeeding is going well, a parent might decide not to move forward with the surgery. Once their child is older, they might decide to get an assessment from an SLP to see if the restriction is causing any issues with speech and then decide on a plan of action from there.
• Occupational Therapist: They may look for effects of an oral restriction in other areas. They may notice something about the way a baby is holding their head, etc. and may be able to recommend other interventions either instead of surgery, or in addition to it.

The understanding of oral restrictions is still in progress. For a long time, this was unknown or just not understood. In the last couple of decades, our awareness of the problem has increased a lot, and it’s possible that there was a surge in diagnosis and treatment that might not have been necessary. We believe a more conservative approach is best. It’s definitely not something that should be ignored, but proper physical AND functional assessment is critical before deciding whether to intervene and how. If your baby is thriving and you are feeling great, it’s usually fine to wait and see!

References:

Ankyloglossia (Tongue-Tie) – StatPearls – NCBI Bookshelf

Postural and cervical proprioceptive implications in adult humans with ankyloglossia: an observational study – PubMed

Is Ankyloglossia Correlated With Pediatric Sleep Disordered Breathing? A Systematic Review – PubMed

Academy of Breastfeeding Medicine Position Statement on Ankyloglossia