If a baby's cheeks are dimpled or they makes a clicking sound when breast or bottle feeding, they is not latched well. It can be a sign of a shallow latch, wrong shape bottle nipple, issues from a small/retracted jaw, signs of a cleft palate, or baby may have a tongue tie. If baby feeds without dimpling or clicking at the breast but has these symptoms on a bottle, consider a different bottle system. If baby has dimpling and clicking on both bottle AND breast, it’s worth further investigating with the help of an IBCLC lactation consultant to figure out why.
It’s the up and down pump action of the middle of the tongue that is essential for creating a vacuum (negative pressure) in the mouth for baby to be efficient at moving milk from the breast. Babies need to be able to protrude the tongue out past the lower gum line AND MAINTAIN IT protruded for the duration of the feeding. Diagnosis of a tie should never be done by visual assessment alone, especially from a picture. A picture is one literal snapshot in time and what the tongue does in that moment is not representative of how it moves spontaneously or when challenges with specific directions. Now there are extreme cases where the tongue is very clearly restricted, but a full assessment is still beneficial. To determine whether a tongue is tied or not, a skilled and highly trained provider should be spending several minutes with your baby, assessing their whole body as well as their tongue. Their fingers need to be in your baby’s mouth to see how the tongue moves, it’s strength and coordination. A full history and a feeding also need to be observed before deciding what kind of intervention may be needed. Does the baby just need to work on reducing tension in their body? Is it how mom is positioning the baby that’s causing pain and damage? It is there an actual lack of functional skill at play? All of this should be guided by a trained IBCLC. Your pediatrician is most likely not trained in this (I’ve seen rare exceptions). And parents on social media groups are certainly not properly trained. They are only coming from their own experience.
There are two kinds of ice in the ocean: icebergs and ice floes. Both can look identical on the surface, but are completely distinct below the water. Icebergs have a portion of ice seen above the surface, and huge, extensive mountains of ice below the surface, anchoring what you can see above to the masses below. Ice floes are seen from above and are basically a sheet of floating ice.
Tongue ties can also be classified into two types: tetherbergs and tether floes.
Tetherbergs are tongue ties that look tied on the surface, but the breastfeeding issues and symptoms are connected to so much more than just the tongue. Baby usually has lots of tension in the body. There may be a sensitive nervous system. A traumatic birth. Baby may live in a state of fight or flight. There may be other asymmetries or structural differences in the body. There’s so much more below the surface than meets the eye. For these babies, doing a revision of the tie is literally only the tip of the ice berg. They usually need lots of pre and post release manual therapy such as chiropractic or craniosacral therapy, occupational therapy, and suck training. It may be weeks to months before what is below the surface is fully addressed.
Tether floes are the babies I dream of in my practice. The tongue tie is the root cause of the breastfeeding problems and symptoms. A simple release is an overnight, miracle cure to nipple pain and damage, weight gain, milk supply or reflux. These babies usually need minimal additional interventions to restore the breastfeeding relationship and have all of their symptoms melt away.
Being aware of the tetherbergs vs the tether floes is the beginning to understanding your journey with a tied baby. Many families have their baby’s tie revised only to find they still have persistent symptoms. For them, the mass of ice below the surface must still be addressed before relief is gained. If you’re in the middle of your journey, keep going. Keep asking questions. Keep finding the highly trained health care providers who specialize in ties who can help.
For more information, see the original post by Michele Chatham
Did you use a nipple shield to help your baby latch? Want to transition baby off the shield? First, weaning from the shield is your choice. If you like it and it’s comfortable for you, don’t feel pressured to get rid of it before you and your baby are ready. There are risks associated with shield use, like the potential for decreased milk supply. But if that’s the only way your baby will latch right now, give yourselves time and grace to keep trying as baby gets older and more proficient at the breast. As always, if you’re really struggling to get off the shield, find a knowledgeable lactation consultant to help you with the process to make sure something else isn’t going on with baby’s latch.
💡You can always start with the shield on and take it off after your first let down once baby is not as hungry or use it on the first side and offer the second side without it
💡Start by trying without the shield once a day during daylight hours when baby is happy and not too hungry. Catching baby with early hunger cues is imperative. If they’re crying and really hungry, try a different time
💡Start in skin to skin. Taking a bath together can help. Try to be as relaxed as possible
💡Try to erect and evert your nipple. Use reverse pressure softening (RPS, see highlight reel), a pump or stimulate your nipples with your hands before attempting to latch
💡Help baby latch with laid back nursing, supporting the breast in a “C” or sandwich hold, or the flipple. Make sure baby’s chin and cheeks are physically touching the breast as much as possible. A baby that can’t feel the breast can’t latch to the breast.
💡Hand express to get your milk flowing so baby gets instant satisfaction and reduce the work
💡Relax and be patient. Babies can feel your energy. The more you can see it as fun practice, the less pressure you’ll put on yourself and your baby
💡Try a nipple shield weaning system like this one from Back to Mom (24mm) or Lacteck (small/20mm).
Lip ties (and their pictures on social media) drive me clinically nuts, because is so much confusion and misinformation about who actually has one. Too often medical professionals and lactation consultants say:
“All babies have lip ties” “All babies have a band under there, there’s no such thing as a lip tie” “That tissue will stretch with time/migrate up as they get older” “They’ll eventually fall and break it on their own. No need to intervene” “It doesn’t cause any problems, so just leave it alone”
On the flip side, some providers (and other random parents on social media forums) will say:
“See how the band of tissue is really low on the gums? That’s a lip tie” “See how thick that band is? That lip is definitely tied” “Lip ties are causing of all your nursing issues, cut it ASAP” “Lip ties will cause all kinds of issues in the future, even if you don’t have symptoms now, better to cut it sooner rather than later” “Where there’s a lip tie, there’s a tongue tie, your baby must be tied if they have any symptoms if a frenulum is visible”
Lip tie
I am the first to refer to the appropriate health care provider (ENT or pediatric dentist) when a true lip tie is not allowing proper function of the lips and is impacting the success of digestion or breastfeeding. But let’s understand a few things:
✏️According to a 1994 study by Flinck, who looked at >1000 babies, 77% of them had a frenulum that inserted “low” on to the gumline. A further 17% had a frenulum that inserted into the palate. So 94% of babies have a really low gum insertion – that is NOT the definition of a lip tie. Having a low set frenulum cannot be the only criteria used for release.
✏️There is currently no published criteria defining a normal frenulum vs a lip tie. That does not mean a lip shouldn’t be addressed when function is being impacted by anatomy. But that band between lip and gums is supposed to be there to some extent to help anchor your lips to your face for proper movement and facial development.
✏️Lip tie, when it is present, can certainly get in the way of a normal latch. A lip tie may cause increased air intake (contributing to reflux and gas), breast pain from the lips gripping too tightly to the breast, contribute to lip blisters muscle compensations, or not allow the baby to be able to maintain the latch through the whole feeding. While the lips are important for feeding, I’m more concerned about the tongue for obtaining a normal latch. Many compensations baby does to overcome a tongue tie may be mimicking issues seen with lip tie. Baby needs assessed for both.
✏️ It is rare for there to only be a lip tie. In the vast majority of cases, where there is a true lip tie there is also a tongue tie. The tongue is usually the reason for the symptoms as the tongue plays the major active role in breastfeeding. If the lip tie is released and symptoms persist, it is worth further evaluation of the tongue. I have had a few cases where a lip tie release only has resolved the breastfeeding issue, usually areola pain or popping on and off the breast from not being able to make a tight seal with the lips.
No lip tie. This is my daughter at 8 months old
True diagnosis of lip tie is all about anatomy (what does it look like), physiology (what does it do), and symptoms (what is it causing). A lip tie will always impact function of the lip by restricting its expected movement. The upper lip should be soft and move to spread and pucker the lips without difficulty. The upper lip should play a passive role when breastfeeding, gently rounding to maintain the seal at the breast so milk doesn’t leak out and not gripping the breast.
An evaluation by an IBCLC should be mandatory before any baby is sent for oral surgery. Are the symptoms and behaviors at the breast being caused by poor position and latch? By tension in the body from birth trauma? Is tongue tie the actual culprit to the issues going on?
👄 The movement of the lip must be physically challenged to determine its full range of motion. If the lip is lifted up toward the nose, the center of the lip should move up toward the nose with the rest of the lip. If the center of the lip stays down against the gum line, it is most likely a tie. If no one physically flipped the lip up toward the nose, lip tie was not assessed.
👄 When you lift the lip, if the gums where the frenulum inserts turns white (blanches) OR the lip skin/frenulum turns white (blanches ) when you lift the lip up with reasonable amounts of pressure, the lip is tied.
👄 A notch in the bone of the gums where the frenulum attaches means the lip is tied. It indicates the tissue is so tight it’s now impacting the bone. This kind of lip tie needs immediately assessed and addressed as it most likely will impact dentition and dental hygiene.
👄 My baby has lip blisters. Does that mean they have a lip tie? Not necessarily. They may have a tongue tie and the lips are compensating for it. They may be constantly in a shallow latch at the breast or bottle and be using their lips to hang on. Lip blisters are a sign of shallow or dysfunctional latch and feeding should be observed to maximize latch.
👄 My baby always tucks their upper lip when nursing. Does that mean they have a lip tie? If the lip is still soft and can easily be flanges out, no, it’s not tied. Some babies like to tuck the upper lip or it gets accidentally tucked when latching and it’s not a problem. Tucking the upper lip can also happen when the tongue is tied- if the tongue can’t hold the seal (which is its job), then the lips have to. If the lips hold the seal, the lips have to be tucked in or milk will leak.
👄 The upper lip frenulum is one that can stretch and migrate up with time. As more teeth come in, the teeth may naturally help close the gap caused by some frenulum. If that is normal, why should it be released? An upper lip frenulum can migrate up over years, but if the restriction of the lip is affecting baby and mom NOW, then it should be treated NOW. Nipple pain and damage may have been normalized by the general public, but that does not mean it is normal. If you’re having symptoms associated with lip tie, have the lip and tongue assessed by someone who can properly evaluate and manage it.
This is the same child as the picture just above. She’s now two years old.
A lot of emphasis is being put on lip ties right now, especially by well meaning parents on social media. Remember: you usually cannot tell if a lip is tied from a picture alone. A full, dynamic assessment is needed. If a health care provider looked at the lip without actually completing a full inner mouth assessment in the lips, cheeks and tongue, and observing a feeding, a full assessment wasn’t made. While a lip tie alone can get in the way of feeding and cause some pretty intense symptoms in some babies, the main focus should be on good position and deep latch with normal tongue mobility.
Normal frenulum. No blanching and lip flips without difficulty
If you’re struggling with breastfeeding, seek out a qualified IBCLC or schedule your consultation with me ASAP to determine your next steps.
As an SLP/IBCLC, I look at three things when doing an assessment on infants: what does the tongue look like, what can the tongue do, what symptoms is it causing. The tongue needs full range of motion (in and out, side to side, and up and down ) for feeding, dental hygiene and to some extent speech. You can have a frenulum can still have good range of motion. A frenulum is considered tied when the tongue can’t move in all directions and it’s causing symptoms because it’s not functioning correctly.
Symptoms to watch out for are:
👅Can not grasp and hold a nipple for breast or bottle feeding
👅Pops on and off the breast/unable to latch or maintain the latch
👅Leaks milk from breast or bottle
👅Fatigues easily from tension on the tongue and jaw/“sleepy” at the breast
👅Wants to feed all the time and never seems satisfied
👅Causes nipple pain and damage when latched
👅Pinches the nipple when feeding causing recurrent plugged ducts and mastitis
👅Doesn’t empty the breast well causing low milk supply
👅Tongue constantly in a “stimulation” mode instead of efficient sucking at the breast, causing an over supply of milk with fast let down
👅Cannot create the vacuum needed to draw breast milk and makes a clicking or loss of suction sound at the breast
👅Poor weight gain
👅Chokes and gags during feeding
👅Fussy at the breast
👅Swallows air while feeding causing reflux, gassiness or colic
When range of motion is restricted, or is causing symptoms, I will refer to a pediatric dentist who also looks at how the frenulum is impacting structure: is it pulling on the structures of the floor of the mouth and the jaw? Is it putting tension on the bone? In those cases, when function is restricted and it is currently causing symptoms, a revision is warranted. I never recommend revision to avoid symptoms down the road. It’s not ethical.
