December 4, 2023
December 4, 2023

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All Tied Up: Unraveling the Complexities of Tongue Tie

Difficulty feeding a new baby can cause frustration and tears in both new and experienced parents. One possible cause for these problems is a tongue tie. When a baby’s tongue tie causes pain and difficulty with breastfeeding or bottle feeding, the right help cannot come soon enough. However, knowing how best to help a baby with a tongue tie can be confusing to parents, especially if they receive conflicting opinions from friends or health care providers. In this article, I hope to thoughtfully unravel the complexities of this issue and guide parents and practitioners through what I find to be the most successful approach.

Let’s start off with a basic explanation of what tongue/lip ties are. A tongue tie (also called ankyloglossia) is a restriction of the tongue frenulum, which is the tissue that connects the underside of the tongue to the floor of the mouth. Other restrictive frenulum can exist under the lip or in the cheeks, and the umbrella term used to describe all mouth ties is tethered oral tissues (TOTs).

When a baby’s tongue is restricted because of a tie, the tongue’s normal wavelike sucking motion cannot be performed. Instead, the baby will utilize suboptimal sucking patterns that can cause pain, breakdown and bleeding for the mother, and poor milk transfer. These sucking patterns can also cause problems for the baby, including increased intake of air, clicking, choking or gagging while feeding and poor weight gain. Lip ties prevent the baby from effectively forming a proper seal with his/her lips when feeding.

So, how do you determine if TOTs are a factor in your baby’s feeding problems? The first thing you will need is a functional assessment, an evaluation of how the tongue moves in relation to the rest of the mouth. This type of assessment is often performed by occupational therapists (OTS), speech-language pathologists (SLPs) and doctors who have specific training in this area. If you remember nothing else from this article, remember this: To properly identify TOTs, a baby needs to have a functional assessment.

In Bergen County, we are fortunate to have many pediatricians who understand the need for a functional assessment. In some cases though, a provider may overlook a tongue tie by visually inspecting the tongue or swiping a finger under the tongue. This is especially true for certain types of tongue ties known as posterior ties which are not visible just by looking under the tongue. When that happens, parents may be left floundering as TOTs symptoms go unaddressed. At the other extreme, it is important not to assume that every feeding issue is caused by tongue tie or that every baby’s visible frenulum is a restrictive tie. As they say, if it ain’t broke don’t fix it.

Once a tongue tie is determined to be an issue, a frenotomy (a procedure to release the frenulum) would seem to be the obvious next step. However, a frenotomy alone does not resolve all feeding issues. A frenotomy only improves the tongue’s range of motion, which is only one piece of the puzzle. Imagine your whole life you ran races with the laces of your two shoes tied together. Not knowing any other way to run, you would figure out a motor plan that would get you across the finish line, albeit not very effectively. All of a sudden one day we cut your laces and tell you to run. Wow! You now have lots of range of motion but your form is poor and you need to create a new motor plan. Same with frenotomies.

Babies first start sucking reflexively in-utero and a tongue tie can cause abnormal sucking patterns and impact the shape of the roof of the mouth even before birth. Therefore, even a frenotomy performed shortly after birth may need to be followed by reteaching the baby how to move its tongue, also known as neuromuscular reeducation. Additionally, there may be some areas of tension from birth and in-utero development that impact the mouth and require other types of therapy known as “body work.”

Given all of the complexity surrounding TOTs, a team approach is key. When symptoms suggest a possible tongue tie, the first step should always be a functional assessment. If a restrictive tongue tie is found, there are a few steps that can help babies before having a frenotomy. These include working out muscular tension, teaching the baby new sucking patterns and teaching parents how to do the post-op stretches before the actual frenotomy so that it is less overwhelming on the day of the procedure. After the frenotomy is performed and the wound has time to heal, the baby may also need some neuromuscular reeducation and/or body work until feeding goals are met.

Among the many professionals who can help on this journey are OTs and lactation consultants (IBCLCs). As both an OT and an IBCLC, I am fortunate to take on a dual role in assisting families through this process. First, I provide lactation support to mothers who are experiencing breastfeeding challenges. As an OT, I perform a functional assessment of TOTs and provide neuromuscular reeducation for the baby before and after a frenotomy. I also teach parents how to perform post-op stretches to ensure their confidence in managing the wound healing process.

I approach this issue not just as a provider, but also as a parent. I personally have experienced TOTs with all four of my children and I am passionate about helping families through this. I hope that by mapping this process out, I can help parents and providers be informed, empowered and prepared when navigating TOTs and work together as a team to help their babies feed, grow and thrive.

Sipporah Tracer is a pediatric occupational therapist and international board-certified lactation consultant in private practice. Complementary in-services about TOTs are available to Bergen County pediatricians upon request. Sipporah can be reached at [email protected] or 718.885.6617.

By Sipporah Tracer, MS, OTRL, IBCLC


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