As a Speech Language Pathologist (SLP) and Certified Lactation Consultant, I am usually not the first stop on a breastfeeding journey. By the time a client finally finds me, they are usually frustrated and ready to give up. I am usually the “last stop” after many dead ends and false reassurances. 

Most of the time, the families who are finally referred to me have already been dismissed by their Pediatrician who has told them “everything is fine” without even performing an intra-oral functional exam. Many families have seen several other Lactation Consultants who have also completely missed the underlying issue. Lactation Consultants are skilled in basic lactation education and support, however most do NOT receive the additional intensive training required to properly identify significant oral dysfunction. Pediatricians (like most general medical practitioners) certainly do NOT receive specialized oral motor/function training, except for rarely some Pediatric Dentists or Pediatric Otolaryngologists who choose to specialize in Oral Restrictions. 

Tongue tie (ankyloglossia) is where the strip of connective tissue that connects an individual’s tongue to the floor of their mouth is shorter, thicker or tighter than usual which restricts the tongue’s range of motion.

An individual with an oral restriction (tongue or lip tie) often has an unusually short, thick or tight band of tissue (lingual, labial or buccal frenulum) which inhibits the ability of the tongue, lips or cheeks to move freely in all directions necessary for speech, feeding, airway and speech. In babies this may interfere with breast or bottle feeding. And untreated oral restriction can lead to a multitude of compensatory health and oro-facial issues. 

Not all oral frenulums are restricted. However, when a restriction is present, it often requires a simple surgical procedure to correct and release.

Tongue tie is a congenital issue that may become apparent soon after birth and occurs when the tongue does not separate from the floor of the mouth during womb development. Note that an individual may be “tongue tied” or restricted to various degrees.

Tongue tie is estimated to affect 4-11% of newborns but may go unnoticed until other issues become evident – see signs and symptoms below.

Tongue ties limit tongue mobility which is important for speaking, chewing, drinking, breathing, swallowing and more. It is also extremely important for adequate craniofacial development. Without identification and intervention, a tongue tie in a child can have downstream affects as a child’s face and head develop.

Myofunctional Therapy is an important aspect for treating tongue tie. Surgery alone does not guarantee success.

Many adults experience symptoms such as swallowing, breathing, and/or sleeping issues and/or upper body tension for years, not knowing that this is a negative consequence of tongue tie. As individuals develop from children to adults, a cascade of Orofacial Myofunctional Disorder symptoms emerge as the body maladapts. These adaptations aren’t viewed as abnormal because the person just doesn’t know any different.

Adults most often complain of poor sleep quality, obstructive sleep apnea (OSA), digestive issues and swallowing problems, teeth grinding (Bruxism), Temprormandibular Joint Dysfunction (TMJ) pain, postural issues, upper body tension, speech impediments, head and neck pain and migraines just to name a few. Adults tend to learn about their own tongue-ties when a child is born with a tongue-tie, and the parents start to understand the familial relationship.

Tongue-tie correction is important for adults too. Even though the frenectomy is not done for breastfeeding issues (as it is done in an infant), or to prevent insufficient craniofacial growth and airway issues (as it is done in children), adults should proceed with a release if the lingual restriction is causing difficulty with correct oral lingual rest posture, nasal breathing, swallowing, speech, feeding or sleeping.

When parents hear about “tongue tie” or search on the internet, they most commonly see images where the tip of the tongue is tethered down to the floor of the mouth. Posterior oral restrictions cannot be visualized. With a posterior tongue tie (PTT) the anterior portion of the tongue is not “tied”. It is often not easily seen or identified as most practitioners are not trained to assess it. One of the most common statements from medical professionals is that “posterior tongue tie is not a thing”. Some of this confusion is the result of a misunderstanding of the anatomy and/or assuming that the tie is located in the posterior oral cavity near the tonsils. This is not accurate.

A posterior tongue tie is the presence of abnormal collagen fibers in a submucosal location surrounded by abnormally tight mucous membranes under the front of the tongue. ALL anterior ties have a posterior element. Therefore, any tongue tie causing breastfeeding problems is truly a posterior tongue tie; a percentage of those ties also have an anterior component. Failure to release ALL of the abnormal collagen fibers result in a continued lingual restriction. When providers are only able to release part of the restriction (incomplete release) there can be very limited improvement in tongue mobility and function. I see this all the time in my practice.

Untreated oral restrictions can present like “normal” benign infant issues such as:

🚩Reflux

🚩Gassiness

🚩Nipple soreness

🚩Low Milk Supply 

🚩Breast Refusal

🚩Inability to Latch

🚩Colic

🚩Neck muscle tightness/Torticollis 

🚩Sleep disruptions 

🚩Slow Weight Gain 

🚩Mastitis/Plugged Milk Ducts

🚩Suck Blisters

🚩Milk leaking from Breast or Bottle

🚩Biting on nipples

🚩Recessed Mandible/Jaw Tension

In isolation, many of these complaints can easily be dismissed as just “normal breastfeeding issues”, when they are actually symptoms of oral dysfunction. Many professionals will try to address each issue individually which will lead to many dead ends without addressing the underlying issue. Without finding the RIGHT feeding specialist who is skilled and knowledgeable in assessment and identification of Oral Restrictions, many women are forced to give up breastfeeding altogether. Had this mom not found me when she did, she and baby would not have been able to sustain a successful breastfeeding relationship. 

Infant Oral assessments can be broken down into 3 parts:
Functional | Visual | Structural

The Functional Assessment

The functional component of the oral assessment is, in my opinion, the most valuable and needs to be done first! The functional assessment involves assessing what your baby physically can and cannot do with their oral anatomy. Functional assessments are carried out in one of two ways, In-Person or Virtual:

1. With an in-person visit: I’m going to pop on a glove and feel around in your baby's mouth. I have a series of short exercises I do to check your baby’s range of motion and reflexes to see if there are any issues with function and to check their oral reflexes.
2. With a virtual session: I have you complete these exercises yourself (don’t worry, I give you instructions that are easy to follow) and answer questions to gather this data. Typically, I prefer to do this before the session so that we have time to do the exercises while your baby is nice and happy to get the best information possible.

The Visual Assessment

The visual component of the assessment involves looking at your baby’s oral anatomy and watching how they are using their oral anatomy to meet their needs. Babies are fantastic at finding ways to work around their challenges which are called compensations. Visualizing their oral anatomy and watching how they feed and compensate at the breast and bottle are absolutely necessary to shape a care plan, but without the functional component, the visual assessment alone often fails to provide lasting solutions. It is also possible to misattribute something you see visually as a problem when the functional assessment may show that, regardless of how it looks, it’s not actually an issue. During the visual component of the assessment, we often trial different positions and techniques to see if we can alleviate the challenges with these strategies.

1. With an in-person visit: This is accomplished by watching you feed your baby at the breast and the bottle. I also visualize your baby’s oral anatomy during the hands on exam to make sure I have seen how the anatomy is structured.
2. With a virtual session: We use videos of your baby crying, videos of you doing an oral assessment maneuver so I can see the frenulums (again, I give you easy to follow instructions), and videos of feeding at the breast and bottle. Some of this we may repeat on a live video call, but I prefer to get video beforehand so that I know we see what we need to see, and we can spend our time together finding solutions since we gathered the data (and likely the answers) beforehand.

The Structural Assessment

The structural component is where we look at the baby’s full anatomy from head to toe. Baby’s are full body eaters, and what’s happening in their bodies is often manifested in their mouths and vice versa. So, we are looking from head-to-toe to see what is going on with your baby’s posture, tension, muscle tone, and reflexes. We are checking for obvious concerns with tone, or issues such a plagiocephally, or tortocollis, as well as the less obvious concerns that can be easily missed by the untrained eye. We check infant reflexes to make sure they are presenting in an age-appropriate fashion.

1. With an in-person visit: This may be accomplished by assessing the baby in live time, or by photos and videos submitted ahead of time. With my practice, I prefer to do all of the same paperwork ahead of time with pictures to review so that I can focus my assessment. The more focused the assessment, the quicker we can get you the answers you are hoping for. It also allows me to assess your baby’s anatomy over several different positions to check for consistent, atypical positioning.
2. With a virtual session: We do the photos beforehand so that we can make sure I have been able to see everything before the session in case baby is not tolerating the camera well, or the connection is unstable. Oftentimes, I am looking for very subtle misalignments and asymmetries, so relying on a video consultation to achieve this isn’t a good plan in my experience.

Because of recent increases in the popularity of breastfeeding, tongue-ties are being identified more frequently in infants. However, there are many children and adults who have tongue-ties but are unaware. It is estimated that 98% of all Pediatricians and Pediatric Dentists do not seek the additional training necessary to be qualified to properly assess for and identify oral restrictions. 

Oral restrictions can NOT be identified visually simply by “looking” in a child’s mouth. A full FUNCTIONAL oral assessment must be performed to 1) identify any oral frenulums and 2) determine if the frenulums are restricted (i.e., tongue ties) and affecting the child’s oral function. Since the majority of Pediatricians, Pediatric Otolaryngologists and Pediatric Dentists are not trained in performing Functional Oral Motor Assessment, the majority of pediatric oral restrictions are overlooked (especially posterior tongue ties that can only be identified by manually manipulating the tongue). 

These unidentified tongue-ties can cause problems not only in infancy but that continue through adolescence into adulthood, ranging from mild to life disrupting. It can take years for someone to stumble upon the right professional who is able to “tie” their troubling health symptoms to their unidentified oral restriction. Unfortunately, many people never realize that they have oral restrictions that are impacting their lives. It is never too late for a person to have their tongue-tie identified and released. The benefits for some people can be life changing and well worth the time and effort. 

• Difficulty elevating the full tongue (anterior, middle and posterior portions)
• Difficulty lateralizing the tongue from side to side (without moving the jaw with it)
• Difficulty extending the tongue out of the mouth (without letting it touch the bottom      teeth)
• Difficulty isolating tongue movements from the jaw.
• Discoordination with sucking, swallowing, or breathing
• Heart-shaped tongue, or inability to form a point at the tip
• Tongue that appears notched
• Trouble breast-feeding / latching
• Problems with eating, speaking or reaching the back teeth with tongue
• Aerophagia which occurs from air swallowing
• food still left on the spoon (upper lip is unable to clear the spoon due to restricted labial range of motion)
• gagging
• coughing
• choking
• not attempting to self feed
• continued used of suckle pattern
• unable to use a straw or open cup
• dental problems such as cavities
• food left between the teeth and cheek
• grazing
• one side chewing 
• poor weight gain.
• Chronic ear infections
• Speech issues
• Delayed speech development
• Crowded teeth
• Dental problems
• Dental hygiene issues
• Overbite
• Jaw pain
• Chronic head and neck pain
• Migraines
• Digestive issues
• Rapid eating behaviors
• Food texture issues
• Picky eating
• Poor chewing
• Drooling
• Mouth breathing (while awake or asleep)
• High arched palate
• Resting tongue posture laying on floor of mouth
• Narrow airways
• Snoring
• Sleep apnea or sleep disordered breathing patterns
• Sleep disturbances

CONSEQUENCES OF UNTREATED TONGUE TIE:   

(Taken from; Tongue Tie – from Confusion to Clarity by Carmen Fernando)

For Infants:

• Impact upon milk supply
• Termination of breastfeeding
• The baby failing to thrive
• Poor bonding between baby and mother
• Sleep deprivation
• Problems with introducing solids

Maternal Experience:

• Pain
• Nipple damage, bleeding, blanching, or distortion of the nipples
• Mastitis, nipple thrush or blocked ducts
• Severe pain with latch or loosing latch
• Sleep deprivation from baby being unsettled
• Depression or a sense of failure

For Children:

• Inability to chew age appropriate solid foods
• Gagging, choking or vomiting foods
• Persistent food fads
• Difficulties related to dental hygiene
• Delayed development of speech
• Dental problems starting to appear
• Strong incorrect habits of compensation being acquired

For Adults:

• Inability to speak clearly
• Clicky jaws
• Pain in jaws
• Migraines
• Receding jaw
• Effects on social situations, eating out, kissing, relationships
• Dental health, a tendency to have inflamed gums, increased need for fillings and extractions
• Difficulty keeping dentures in place

⚠️If the ties continue to remain untreated, children may have difficulty with speech since the tongue and lips cannot form the proper positions to create certain sounds. Sounds like K, G, NG, SH, CH, TH, T, D, N, L, R, S and Z will most likely be affected.

⚠️And lastly, in children and adults, some common problems include TMJ disorders, frequent headaches, migraines, braces, palate expansion, chronic dental issues, and chronic neck pain. Click here for more info regarding adults & adolescents with oral restrictions.

If you have any concerns that your baby or child has an Oral Restriction (Tongue Tie), please schedule an assessment.