While maternal nipple pain and damage are classic signs of tongue tie in baby, I have seen many cases where the mother reports absolutely no pain with breast-feeding. These babies tend to have very high palates and some times a weak suck (not always). The actual nipple in most cases is large and long and goes up into the palate where the tongue tends not to be able to pinch it as much. There may be creasing of the nipple, but usually not the classic damage seen with other presentations of tongue tie. These mother‘s bodies often compensate with a fast let down and over supply of milk. These babies trigger let down easily and the mothers body responds with freely flowing milk. Baby drinks from the fountain without learning how to stimulate the breast and empty it on their or or learning how to trigger new let downs. These babies often gain weight well or even faster than expected until around 3-4 months when they unexpectedly drop off the growth curve and mom feels like her supply suddenly drops. Symptoms often include clicking at the breast (caused by that high palate and the fast flow of milk) which in turn increases the risk of reflux, colic and gassiness. Moms also complain that they need to constantly hold or shape the breast or baby loses the latch. These ties often go undiagnosed and many of these babies are switched to bottles and formula as the supply continues to decrease from the baby inefficiently moving milk from the breast which can also coincide with mother going back to work. If she is using a poor quality pump or the wrong size flanges and not moving milk well with the pump, she’ll often blame herself for the low supply.
Some times even the best lactation consultants and feeding therapists can miss a posterior tongue tie in the immediate days or weeks after birth. Having a frenulum under the tongue doesn’t automatically mean it’s tied. A long, stretchy frenulum that allows full movement of the tongue is normal and not something that needs released. However, sometimes a frenulum can allow the front of the tongue to do what it needs to, but still be tied at the back. These are what I can tricky posterior ties. Mom may have lots of milk and baby transfers well from the breast in the early days or weeks post delivery. Mom may have no nipple pain or damage whatsoever. Only they come back a month later with new symptoms like slow weight gain or feeling like there breast isn’t emptying. Why is that?
Mom’s body often compensates well during the early weeks post delivery. The uterus doesn’t tell the breasts how many babies came out. So her body goes into overdrive to make more milk than needed from the start. As time moves on, the body figures out how much milk to make and drops supply to just what is being emptied. A baby that rode on mom’s robust post delivery flow may all of a sudden start to struggle at the breast as supply regulates. Based on how the anatomy is, there may never have been nipple pain or damage. If the baby has a high palate where the front of the tongue can still move well and mom has a large nipple that fills baby’s mouth well, the nipple may come out creased or pinched, but without pain. The anatomy on one or both sides masked the tie while baby was small.
If breastfeeding was going well in the beginning, but symptoms start to pop up later, working with a qualified lactation consultant can help figure out what’s going on. And some times that means finding a posterior tie that was originally missed where a release is necessary to get feeding back on track.
My baby is spitting up a lot. Is that normal?
Reflux occurs when milk flows back up (refluxes) from the stomach, causing baby to spit up. In babies, the ring of muscle between the esophagus and the stomach, the lower esophageal sphincter (LES), is not fully mature, so stomach contents can flow backward. With time, the LES opens only when baby swallows, keeping stomach contents in the stomach. It is rarely serious and becomes less common as baby‘s system matures.
Baby spit up for lots of reasons:
- Baby is not be able to swallow quickly enough when milk ejects forcefully during let down, resulting in swallowing extra air.
- Mom has an oversupply of milk and baby takes too much too fast for the stomach to handle.
- Tongue or lip tie causing baby to swallow more air
Less common reasons:
- Immature muscle control
- Allergy to foods and/or dietary supplements mother may consume
Spitting up occurs in healthy babes multiple times a day. As long as baby is healthy, happy and growing well, spit up is not a concern.
See your baby’s doctor if your baby:
- Isn’t gaining weight
- Refuses to feed from breast or bottle
- Consistent, forceful spitting up (projectile vomiting)
- Green or yellow fluid spit up
- Spitting up blood or material that looks like coffee grounds
- Blood in baby’s poop
- Difficulty breathing or a chronic cough
Help reduce reflux:
🍽Feeding positions: baby’s head higher than their tummy, such as a laid-back position or koala hold. Avoid positions that have baby bending at the waist, putting more pressure on their belly. The mama in this picture is practicing an upright, side lying to help reduce reflux.
- Keep baby upright 15-20 minutes after feedings to aid digestion.
- Shorter, more frequent feedings, to reduce the volume in their tummy at any given time and to keep your breasts filling with a higher water content milk
- Try nursing with only one breast each feeding to avoid two strong milk ejections, reducing overfeeding and excess swallowing of air.
- Burp frequently, after each breast and at the end of feeding.
- If reflux is severe or painful see your pediatrician for medication, which should be the last resort.
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
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”
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.
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.
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.
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.
Tongue tie, technically known as ankyloglossia, is a condition present at birth that affects an estimated 2-5% of all babies born. It is characterized by a short, thickened, or abnormally tight lingual frenulum, which is the tissue that connects the tongue to the floor of the mouth. Depending on the severity of the tongue tie, range of motion of the tongue can be restricted. In very severe cases, the tip of the tongue can appear to be heart shaped. Because of this anatomical difference, sometimes tongue tied babies can’t maintain a latch for long enough to take in a full feeding. Others may appear to breastfeed for long periods of time without actually be effectively transferring milk. Some tongue tied babies will successfully breastfeed only during “let-down”, when the milk flows on its own from the breast into the babies’ mouths, but won’t be able to actively express milk out of the breast on their own. Many babies with tongue tie also have a lip tie, an abnormally tight membrane attaching their upper lip to their upper gums. This can be seen by rolling the upper lip upward. Babies with lip tie often have difficulty flanging their lips properly to feed which impacts their ability to latch well. This can cause them to take in excess air during breastfeeding which often makes these babies gassy and fussy.
While many pediatricians do not see tongue tie as an issue, current research and literature suggests that it can have a significant impact on breastfeeding. However, the American Academy of Pediatrics, among others, have documented the negative effects of tongue tie on breastfeeding. The most common complaint of mothers with tongue tied babies is sore nipples, which is due to poor latch and inefficient sucking. Other breastfeeding problems for the mother can include recurrent plugged ducts, mastitis or thrush, vasospasm, and supply difficulties. Babies with tongue ties typically have difficulty latching, make click sounds while nursing, may be gassy and fussy during feedings, and have slow weight gain despite having mothers who use correct positioning and nurse frequently.
Some babies with very short or thick lingual frenulums are able to compensate well and breastfeed without difficulty. Tongue tie needs to be diagnosed by function and not just appearance, so what the baby’s tongue looks like is not as important than what it can do. According to one study, simple inspection of a tongue-tie is not enough to determine which infants will need medical intervention. However skilled professionals will complete a clinical assessment which includes observation and measurement of the effectiveness of feeding to help determine appropriate action to improve breastfeeding skills. This is not a comprehensive list for tongue function, but it may give you an idea for why your baby is having breastfeeding difficulties:
- Does the tongue elevate? When the baby cries the front edge of the tongue should come up at least as high as the corners of the baby’s mouth.
- Does the tongue extend? The baby’s tongue should be able to protrude or stick out at least past the lower gum if not to the border of the lower lip
- Does the tongue lateralize, or move side to side? Tracing the baby’s bottom gums triggers a reflex for the tongue to follow the finger..
- The baby’s tongue should be able to lift towards the roof of the mouth and touch behind where the upper teeth will come in. Is there a membrane there that prevents the tongue from lifting? When very tight from tension, the membrane may appear white.
If it is determined that the tongue tie is indeed the culprit for breastfeeding difficulties, some pediatricians, ENTs and dentists can perform a frenotomy or frenectomy. This is a quick procedure to cut the frenulum which returns the full range of motion of the tongue and upper lip. Specialized scissors may be use to simply cut the tongue or lip tie. Some prefer to use lasers, which have the benefit of minimizing the amount of bleeding during and after the procedure and decrease the chance that the frenulum will grow back. Many practitioners use a local topical anesthetic to numb the area before the procedure and some use an injection of anesthetic as well. Babies can breastfeed as soon as the procedure is done. Post-procedure care should be done to minimize the frenulum from growing back. Current research shows this is a safe, easy procedure with minimal risk to the baby. The majority of mothers notice an immediate difference in breastfeeding effectiveness and a significant reduction in nipple pain.
When should the frenotomy be done? Current research shown between 2-6 days after birth to establish proper breastfeeding patterns. This same study showed that waiting more than four weeks for frenotomy drastically increased the likelihood that mothers would abandon breastfeeding all together.
If you suspect your baby has a tongue or lip tie, set up a consultation for a full assessment of your baby’s oral motor skills.
For more resources and articles, see Breastfeeding a Baby with Tongue-Tie or Lip-Tie at kellymom.com
- Lalakea, M. Lauren; Messner, Anna H. (2002). “Frenotomy and frenuloplasty: If, when, and how”. Operative Techniques in Otolaryngology-Head and Neck Surgery. 13: 93. doi:10.1053/otot.2002.32157.
- Wallace, Helen; Clarke, Susan (2006). “Tongue tie division in infants with breast feeding difficulties”. International journal of pediatric otorhinolaryngology. 70 (7): 1257–61. doi:10.1016/j.ijporl.2006.01.004. PMID 16527363.
- Emond A1, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. “Randomized controlled trial of early frenotomy in breastfed infants with mild to moderate tongue-tie.” Arch Dis Child Fetal Neonatal Ed. 2014 May;99(3):F189-95.
- Jack Donati-Bourne, Zainab Batool, Charles Hendrickse, Douglas Bowley “Tongue-Tie Assessment and Division: A Time-Critical Intervention to Optimise Breastfeeding/” Journal of Neonatal Surgery 2015; 4(1):3
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- Messner, Anna H.; Lalakea, M. Lauren; Aby, Janelle; Macmahon, James; Bair, Ellen (2000). “Ankyloglossia: Incidence and associated feeding difficulties”. Archives of otolaryngology—head & neck surgery. 126 (1): 36–9. doi:10.1001/archotol.126.1.36. PMID 10628708.
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