Common Breastfeeding Concerns: Tongue and Lip Ties

photo credit: Ashlee Hayden Photography

Common Breastfeeding Concerns: What’s the Deal with Tongue and Lip Ties?

Written by Robin Kaplan, M.Ed., IBCLC, Owner of the San Diego Breastfeeding Center

 If you are a breastfeeding/chestfeeding parent, you’ve most likely been warned about tongue/lip ties.  Some say that ties are the cause of all breastfeeding challenges.  Some say they are overdiagnosed.  Some parents experience great improvement in breastfeeding/chestfeeding after the ties are surgically released and others find no improvement at all.  

So, what’s the deal with these tongue/lip ties?  What are they and do they really make breastfeeding more challenging?  What should a parent do if they think their baby has ties? Read on to learn more...

What is a tongue tie and lip tie?

• Ties refer to a band of tissue (also called a frenulum) underneath the tongue, upper lip, and cheeks that may or may not tether the tongue, upper lip, or cheeks and restrict range of motion.
• All people have frenulums, but to have tethered oral tissue (TOTs) means that the frenulum is restricting range of motion and impacting function, like a tight rubber band. Here is a handout that includes many of the symptoms that can be related to TOTs.
• These TOTs do not stretch over time, but some children/adults learn to compensate despite the tightness. This is why some children and adults don’t show or feel that they have long-term complications.
• Releasing restricted frenula can have a profoundly positive effect on both parent and baby and their ability to meet their breastfeeding goals, but is not always necessary.

How are TOTs identified?

• Some might be identified by a medical professional, like a pediatrician or midwife.
• Typically, International Board Certified Lactation Consultants (IBCLCs) identify tethered oral tissue because they are the professionals completing full oral/feeding assessments. These assessments show whether the frenulum is restricting mobility and the ability to breast/chestfeed well. 
• IBCLC assessments are not 15 minute well-baby checks. They are extensive assessments, lasting 1-3 hours, using research-supported evaluation tools. 
• TOTs cannot be evaluated just by looking in the mouth or at a photo of the mouth, tongue, and lip. Function must be taken into account.
• Parents should be walked through each part of the oral/feeding assessment so that they can make an informed decision about what is best for their child.
• It is always necessary to go back to basics (positioning and latch) first, before blaming a tongue or lip tie. If the symptoms for the breastfeeding/chestfeeding parent or baby are not relieved with the basics, then further assessment is necessary.

It seems like every baby who has breastfeeding challenges has a tongue tie.  Are they just being over diagnosed now?

• TOTs are nothing new. Tongue ties and frenotomy (releasing the TOTs) descriptions can be found in early Japanese writings, other historical documents, and even the bible.  In the 1600s, frenotomy was widely known and there is documentation that describes that midwives would keep one fingernail long and sharp so that she could release the tight frenulum without the use of an instrument.
• Increased research and ultrasound investigation on how the tongue, lips, and cheeks function while feeding have shown what is necessary to achieve comfortable, effective breastfeeding/chestfeeding and milk removal. This information was not available until the past two decades, which is why this conversation is more prevalent.
• There has been a shift in the international culture to be more pro-nursing than it was during the 1900s. With this pendulum shift to positive views about breastfeeding/chestfeeding, parents want answers when challenges arise.  And some of these challenges can be attributed to TOTs.

What should a parent do if they suspect that their baby has a tongue/lip tie?

• Make an appointment with an International Board Certified Lactation Consultant (IBCLC) who is well versed in ties and oral/motor function.
• Have the IBCLC conduct a full oral and feeding assessment - this includes checking the mobility and function of the tongue/lip/cheeks with a gloved hand, as well as while breastfeeding/chestfeeding
• Confirm that the symptoms you/baby are experiencing cannot be corrected with proper position/latching techniques, therefore the oral tissue is tethered (tight/restricted)
• If TOTs are identified, consider contacting a preferred provider who specializes in the diagnosis and possible release of the tightened frenula. This would be an ENT, some pediatricians, and some pediatric dentists. Your IBCLC should be able to offer some referrals.
• If a frenula release(s) is recommended, use post-frenotomy exercises for at least 4 weeks to prevent reattachment and follow up with your IBCLC for continued lactation support.

For more information about tethered oral tissue, check out these resources:

Latch: a Handbook for Breastfeeding with Confidence at Every Stage by Robin Kaplan, IBCLC

Dr. Ghaheri’s website

SOS for TOTs by Lawrence Kotlow, DDS

Tongue-Tied by Richard Baxter, DMD, MS

Kellymom: Breastfeeding a Baby with a Tongue Tie or Lip Tie (Resources)

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Robin Kaplan is an International Board Certified Lactation Consultant (IBCLC) and founder/owner of the San Diego Breastfeeding Center.  Over the past 10 years, she has helped thousands of families overcome breastfeeding/chestfeeding challenges through her in-person and virtual consultations.  Robin is the author of Latch: A handbook for breastfeeding with confidence at every stage and an online class, Breastfeeding for the Working Parent.