Oral Ties/Restrictions
Breastfeeding is hard, and it can be harder due to factors such as oral ties. Oral ties seem to be quite controversial in today’s society among providers. But when our daughter was born and we experienced oral ties it truly opened our eyes up and since then we have been on the lifelong journey of learning from other providers in the field and educating our patients.
What are they?
Oral Restrictions are defined as unusually shortened, thickened, or tightened lingual frenulums. Frenulums are normal anatomical structures of the mouth but it is important to note that when shortened, tight, or thickened they can cause restrictions in the mobility and function of the mouth.It is so important that a proper evaluation of FUNCTION be assessed versus simply a visual examinations when getting assessed for oral ties. There are a few different locations this can occur at including the tongue, lip and cheeks. This anomaly restricts normal oral movements and can interfere not only with breastfeeding but many other functions.
Location of Oral Restrictions
Tongue- ties
A tongue tie is characterized by an unusually shortened, thickened, or tightened frenulum under the tongue that tethers the tongue to the floor of the mouth. This causes the tongue to have a lack of full range of motion. Babies will often have a low tongue posture, which means that the tongue rests on the floor of the mouth as opposed to the roof of the mouth. When this is the case, babies have an inability or diminished capacity to raise their tongues up to contact the nipple during breastfeeding or bottle nipple during bottle feeding, resulting in weak intra-oral pressure which may interfere with breastfeeding. This can also cause a high palate with limited space and a hypersensitive gag in the child. A baby with a tongue tie may have trouble lateralizing their tongue as well which is necessary for optimal hard palate and cranial development.
Lip ties
A lip tie is a condition characterized by unusually shortened, thickened, or tightened frenulum located in the middle of the top lip that causes the skin of the upper lip to attach to the gums. When pulling the top lip up to the baby's nose you may notice the gums blanching white or inability to reach the nose. This restriction makes it hard for an infant to move their lips freely and latch deep enough for an effective feed. You may notice that your baby's upper lips are not flipping out or you constantly have to “flip the lip” when nursing or bottle feeding.
Buccal tie
A buccal tie is an abnormally tight frenum in the upper lip/ side of the cheek area in the mouth. When pulling the cheeks back, you will notice the frenum blanching the gums white. It might elicit pain from the patient, and it will look like the sail of a sailboat. This tie can cause receding gums as the infant ages. Buccal ties also cause a lot of mouth tension which makes it hard to move the lips. These can be the cause for dimples because the frenum is so tight that it pulls the cheek in.
Indications and Symptoms a baby may have oral restriction:
Many first indicators that a mother may experience indicative of oral ties tend to be trouble latching or breastfeeding.
A mother may experience pain when nursing.
They may feel the baby making a chewing/chomping motion with the mouth instead of a sucking motion in order to get milk.
The mother may also notice a clicking sound while the infant is trying to feed whether on the nipple or bottle
The infant may try to feed very often, cluster feeding, because they are unable to get enough milk in one sitting.
The infant may spit up or choke on the milk while feeding.
The baby may seem colicky or experience a lot of gas and fussiness. This can be due to a poor latch which causes the infant to swallow a lot of air when feeding whether on breast or bottle.
The child may have poor weight gain
Parents may notice lip blisters on the top and/or bottom lips
The end of the tongue may be heart shaped which may indicate a tongue tie
Having to constantly ”flip the lips” may indicate lip or buccal ties
Popping on and off frequently when nursing
White coated tongue
A high arched palate with a strong gag reflex
When baby cries the tongue may lay flat in the bottom of the mouth (babies tongue should elevate when they are crying)
Symptoms a mother may notice on herself that the baby is tied.
When your infant is tied it may cause more pain and possibly damage to your nipples.
You may notice a deformed or lipstick looking nipple.
When your infant is struggling to efficiently empty the breast they may cause engorgement or clogged ducts.
You may also notice an issue with milk supply, that being either too much or too little.
It's not just about the feeding journey though. Oral Restrictions can also affect
Delayed speech development
Picky eating
Poor chewing
Dental hygiene issues
Drooling
Snoring
Mouth breathing
High arched palate, consequent narrowing of airways, and the potential for sleep apnea or sleep disordered breathing patterns
Sleep disturbances
If you are having any of the symptoms above it is important that you find the correct provider in order to resolve some of the issues, improve your breastfeeding or feeding journey, and get a proper evaluation and assessment of your child. As mentioned above, because oral frenulums are a normal structure it is important to have a functional assessment to ensure proper oral function is present. You want someone who will get their hands in the baby's mouth, watch them feed/nurse, and evaluate the suck function.
A pediatric dentist is the gold standard for diagnosis of Oral Ties however a well trained lactation consultant is usually seen prior to the dentist.
Treatment
Oral ties are diagnosed during a physical exam by a pediatric dentist or lactation consultant who specialize in pediatrics and oral ties. It is important to note that a pediatrician will not always evaluate these.
It is also important to find providers to assess the entire body as well. There is a strong correlation with body tension elsewhere correlating with oral restrictions. We are seeing a great connection between oral ties and torticollis.
It is crucial for optimal success to address both the body and the mouth tension before and after treatment to ensure proper functionality and excellent treatment outcomes. The work PRIOR to the actual laser removal is just as important than the actual revision to ensure baby is ready for the revision and can get full benefits of the procedure itself.
The main treatment for oral ties is a minor oral procedure where the dentist will use a laser to detach the ties. The procedure is done fairly quickly and causes little to no discomfort to the infant. The mother may even breast feed after the procedure is done. There will be a list of stretches that the dentist will give in order to prevent the tension in the ties from coming back and to help with gaining movement in the once constricted areas.
Complications are very rare but can include some bleeding and infection. It is possible for a reattachment to happen if the parents are not up keeping their exercises or body tension is not addressed.
The release is not the end all be all however for great results. Just like when an adult has surgery they go to rehabilitation to resume function it is essential a baby also seek some type of care following a release to ensure they relearn proper suck function and utilize the mobility of the now oral tissues. Providers to seek include lactation consultants to ensure proper latch and mouth function is obtained. Pediatric Chiropractors, Occupational Therapist, and/or Physical Therapist for adjustments and body work to release tension and restore optimal function of the child's body. Proper neck and body movement are needed for optimal mouth and jaw function.
Personal Story:
When our daughter was born it opened our eyes to what oral ties were and on the way we learned a great deal from the best of providers around the area and now I see similar issues/cases multiple times a day. I love being able to help mothers and families with the struggles we went through and watch them come out on the other end of it just as we did.
When our daughter Oaklee was born we initially had a lot of trouble breastfeeding and getting her to latch. It was very painful and although she was gaining weight there were many other red flags like a preference to turn to the right, popping on and off of the breast, reflux, open mouth posture, rigid and stiff body with arms hugged tight to her body, toes curled, hands in a fist, and clicking when nursing. We initially reached out to our lactation consultant and knew a release was in our future. At two weeks old she had her tongue, lip, and buccal ties released and we started the rehab process with Occupational therapy, Craniosacral therapy, and chiropractic care to take address the body tension and regain function of her oral muscles.
We saw progress right after the release. I no longer had pain and Oaklee seemed a little less tense all the time. However we were still having symptoms like popping on and off, gagging with bottles or pacifiers, mucus in the stool, reflux, and having to continue to flip the lip on bottles, so we had to have it redone at 4 months old which was then the game changer. This is not a usual situation but I knew we had goals we wanted to accomplish and for my patients I wanted to see it through. I am grateful of our journey because it led me to meet and work with some fantastic providers in this field and allowed me to gain experience, education, and empathy for my patients who are going through the same thing but seeking the same goal/outcome I had.
It was a lot of hard work no-one prepared me for and took a lot of patience. It probably took until she was 5-6 months old until we felt comfortable with our breastfeeding journey. So wherever you are at, you got this mama and you're doing a great job. If you need support, I got you.