After having problems establishing a breastfeeding relationship with our first three children, I discovered what a lip tie was. After having our fourth child, I finally learned what a tongue tie was. Had I known about these two conditions from the very beginning, it would have made things a heck of a lot easier! This is the information I have gathered doing extensive research, talking to experts, and through my own experience. This is the information I wish I would have had with my first child from day one and what I would like to tell anyone else who is going through the same thing.

Let’s Talk About Frenula

Frenula is the plural form of frenulum. A frenulum (also called frenum when in relation to the upper lip) is a small fold of tissue that secures a mobile organ in the body. The maxillary labial frenum is the membrane that attaches the gums to the upper lip and the lingual frenulum is the membrane that attaches the base of the tongue to the floor of the mouth.

When a baby is growing in utero, the tongue starts to develop at about 4 weeks. By 6 weeks, the frenulum cells attaching the tongue to the floor of the mouth begin retracting from the tip of the tongue increasing the tongue’s mobility. Disturbances during this stage cause ankyloglossia, or tongue tie. The tip of the tongue will continue to elongate after birth which is why some people believe that the tongue will “stretch” with age and growth, although that is not the case.

Look at Your Frenula

Before going any further, I suggest that you look in a mirror and lift up your upper lip. You may notice a stretchy piece of tissue hanging out up there, and you might even be able to feel it with the tip of your tongue. You may also feel nothing. Next, lift up your tongue and look for the stretchy piece of tissue lying underneath. Move your tongue around and notice the range of motion you have. Then try sticking your tongue out. Notice how far you can stick it out. Can it go down the length of your chin or up to the tip of your nose or does it barely leave the confines of your teeth? After you explore your own frenulums, examine your spouses. The two of you will probably be much more willing participants than your children, and it will give you a good insight as to what to look for since genetics will probably play a role in the type of frenulums your children have.

Are the Frenula Causing Problems?

The mere existence of frenula does not constitute a problem, it is when they are so restrictive that they prevent breastfeeding from occurring that is a problem. When the frenum of the upper lip or the frenulum of the tongue start to cause problems, they are referred to as lip ties and tongue ties. If there is a lip tie, there is probably a tongue tie also, but a tongue tie does not necessarily indicate that there will be a lip tie.

What is a Tongue Tie?

Being tongue tied is medically defined as having ankyloglossia, which is caused by having an unusually short or thick membrane under the tongue that is attached abnormally close to the tip of the tongue and causes restricted movement of the tongue. People with more severe cases of tongue tie cannot stick their tongues out very far beyond their teeth.

Baby Julian’s Tongue Tie

This can cause breastfeeding problems with babies and speech problems as they get older. As an adult, the worst of the lingering effects are typically the inability to French kiss properly and the inability to lick an ice cream cone. Here’s a great 2 minute video describing what tongue tie is, the symptoms associated with it, and what it looks like to get it removed using the scissor method.

What is a Lip Tie?

Having a lip tie occurs when the membrane under the top lip is unusually thick and attaches under the gum line. It is not as common or severe of a diagnosis as being tongue tied, although it does have its own host of problems. I’ve read that severe lip ties will usually correct themselves by the time a child reaches adulthood due to tripping and falling or any other number of accidents that can lead to the lip tie being torn, but Dr. Kotlow, a leading expert in tongue and lip ties, believes this is not the case. He explains how if a severe lip tie is not corrected, “it can lead to dental decay on the upper front teeth, gaps (diastemas) between the two front teeth, orthodontic or periodontal problems later in the child’s oral development, and poor lip mobility or function, especially during smiling and speaking.”

Baby Julian’s Lip Tie

Other resources that I’ve looked at say that once all of the permanent teeth come in, the gap may just fix itself. Here’s a great 2 minute video describing what a lip tie is, the symptoms associated with it, and what it looks like to get it removed using the scissor method.

Classifications of Tongue and Lip Ties

Although you cannot diagnose tongue and lip ties by looks alone, it’s a good place to start. One of the first things to look for to see if your baby is tongue tied is to see if your baby’s tongue makes a heart shape when he or she cries. This is a tell tale sign that it is being tethered too tightly to the floor of his or her mouth.

One of the best ways to look for a tongue tie is to lie the baby on his or her back on your knees with his or her head facing towards you and his or her feet facing towards your knees. Then, tilt the baby’s head back and stick your fingers underneath the tongue to elevate it. You can also get a pretty good look when he or she is crying. To look for a lip tie, look to see if the top lip flanges out while nursing. You can also simply lift up the top lip and look.

These pictures below have been compiled by Dr. Kotlow, one of the most renowned pediatric dentists, known for his skill at correcting tongue and lip ties. He comes highly recommend by Mommypotomus who also has a great blog about tongue ties. You’ll notice that there are many different classifications.

Symptoms of Tongue and Lip Ties

Looking at the symptoms related to tongue and lip ties is actually the best way to diagnose them. So here are a list of symptoms to look for in both mom and baby that could be the result of tongue and/or lip tie.

Symptoms to Look for with Mom
- Nipple pain and/or erosions
- Nipple looks pinched, creased, bruised, or abraded after feeds
- White stripe at the end of the nipple
- Painful breasts/vasospasm
- Low milk supply
- Plugged ducts
- Mastitis
- Recurring thrush
- Frustration, disappointment, and discouragement with breastfeeding
- Weaning before mom is ready
- Tired momma, from being up in the night every hour for feeding night after night after night

Symptoms to Look for with Baby
- Poor latch and suck
- Unusually strong suck due to baby using excess vacuum to remove milk
- Clicking sound while nursing (poor suction)
- Ineffective milk transfer
- Infrequent swallowing after initial let-down
- Inadequate weight gain or weight loss
- Irritability or colic
- Gas and reflux
- Fussiness and frequent arching away from the breast
- Fatigue within one to two minutes of beginning to nurse
- Difficulty establishing suction to maintain a deep grasp on the breast
- Breast tissue sliding in and out of baby’s mouth while feeding
- Gradual sliding off the breast
- Chewing or biting on the nipple
- Falling asleep at the breast without taking in a full feed
- Coughing, choking, gulping, or squeaking when feeding
- Spilling milk during feeds
- Jaw quivering after or between feeds

Symptoms I Had: With our fourth baby, Julian, I was not getting very much sleep because he was up every hour or two (or sometimes every 30-45 minutes) to nurse. And when I would nurse him, I wasn’t able to just lay down and nurse, I had to either sit up on the edge of the bed or in the rocking chair to help him latch on. My nipples weren’t really sore (after four babies, they got pretty tough), but he was rolling the nipple around in his mouth and falling off the nipple repeatedly. When he would nurse, there was a noticeable clicking sound from his inability to form a secure latch. He especially had trouble maintaining a latch during my letdown and he would sputter, choke, and pop off the breast. He would also fall asleep mid feed and as a result he didn’t fully drain the breast. This led to me getting plugged milk ducts (which I massaged away after applying a hot compress and drained completely using a breast pump), and I believe that this is what led him to have a lot of green poops (from not getting enough hindmilk). He was also taking in a lot of air during feedings which resulted in him being gassy, needing to burp and fart a lot, and getting the hiccups. When he had gas (which was often), he would get really fussy and squirm, wiggle, and grunt…even in his sleep. He would also puke a lot, but he also would nurse a lot, so weight gain was not an issue. Finally, at his six week checkup, the midwife noticed that he was tongue tied. Once I started researching the symptoms, it all made sense.

Temporary Relief

If you are waiting for a corrective procedure or trying to decide if you will get one, the following strategies may help to provide some temporary relief.

Stretch the Lip Tie – To help with stretching out both Ophelia and Julian’s lip ties, I would put my finger under their upper lips and roll up. I tried to remember to do this before every feeding. To help them latch on, I would have to grab my breast and angle the nipple down, wait until they opened their mouth, and then torpeedo my nipple in there! Once they latched on, I would sneak my finger under their lips to flange it out. By the time they were three months old, I didn’t have any problems with their lip ties anymore.
Sitting Up and Leaning Forward to Nurse – Getting a good latch is difficult enough as it is, but when you’re dealing with a lip and/or tongue tie, it’s even more challenging! This seems to help.
Burp Often – Because they are taking in a lot of air, it can help to burp during a feeding by either patting their backs or putting them up on your shoulder. I would also try to angle their bodies to make them more upright while nursing. Also, keep burping periodically even long after the feeding.
Hold to Sleep – Now, I’m a really light sleeper, so this works well for me, but it can be dangerous, so use this strategy with caution! What I do is prop a big tower of pillows in a U-Shape around me for support. Then I sleep with pillows propped under my arm and my head leaning against a pillow. When we sleep, I hold his upper body upright and about every 3o minutes or so when he gets fussy, I would pat his back, bounce, and rock him until he calmed down. We are six weeks after the procedure and Julian is 3 months old, and I still actually hold him while I sleep every night. I think I’m just used to it now!
Belly Band Over the Boobs – You know that thing that you put over your pants when you’re pregnant so that you can leave your pants unbuttoned as your belly grows? Well, I pull that over my breasts because my nipples are just so dang sensitive. It’s a much more comfortable alternative to wearing a bra at night and makes it easier to nurse too.
Air Time – Putting breast milk on my nipples and just walking around without a shirt on felt good. (I just had to remember to close my curtains!)

Options Moving Forward

You have several different options depending on your specific situation. You will want to consider the following: the problems you’re having breastfeeding (If it’s not causing any noticeable problems, I would recommend leaving it alone.) the availability of a skilled practitioner in your area or your capability of traveling, your financial situation and insurance coverage, the age of your child (over 6 months is almost too late), and so on. Here is a list of the next possible steps.

Wait and See – If your symptoms are not that bad or if you feel like they may be caused by something else (a poor latch, strong let down, flat nipples, etc.) you might want to take a wait and see approach. Dr. Kotlow however. strongly advises against this for a lip tie because he does not feel that it will get better with time. But with Ophelia and Julian’s lip ties, I saw that they did, although they were not extremely severe. It was really hard to get a good picture, but you can kind of see Julian’s below. It attaches below the gum line and was kind of tight at first, but seemed to stretch out over time. (Sorry about your nose buddy.)
Best Time to Act – Keep in mind that the younger the child, the easier it is to deal with this procedure. Once you go through with the procedure, not only will your child have to physically heal, but he or she will have to learn how reuse his or her tongue based on the release and the new muscle use related to the increased mobility. The best time to get a procedure done is before the child is 3 months old, and really, the younger, the better. Usually, when the child is over 6 months old, the doctor won’t do the procedure in the office, and it will have to be done in the hospital with anesthesia.
Pediatrician’s Opinion – We did not need a referral to get an appointment with a specialist, but you might, and this would be a good place to start to learn about your options. Just keep in mind that some pediatricians are not familiar with tongue or lip ties or worse yet, might not believe in them and make you feel silly for even asking. We took our fourth baby, Julian, to see his pediatrician because we had no idea where to even start. She said, “Yup, that’s a tongue tie!” and suggested that we see an ENT for a frenectomy (also known as a frenulectomy, frenulotomy or frenotomy – which is the removal of a frenulum). When he cries, you can see the heart shape of the tongue and how it is tethered to the floor of his mouth.
ENT – That’s an Ear, Nose, and Throat specialist in case you didn’t know (I didn’t). Some people feel like this is the best place to go for getting a tongue or lip tie procedure. For us, we needed something close that was in our network, and this was the only option. We had to pay $45 for the office visit and we were quoted that the procedure would be $450, but six weeks later, we have yet to get a bill. (Maybe insurance is covering it after all?)
Pediatric Dentist – Some people feel like this is the preferred specialist for this procedure. I think that it all depends on what is most convenient for you. If you can travel and money isn’t an option, then you might have the freedom to research all specialists nationwide and find the best of the best.
Scissor Method – This is the most common way of doing the procedure, and what we did with Julian. Depending on the severity of the tongue tie, a topical and/or local anesthetic may be used, the membrane may be clamped to stomp blood flow, a nurse (and you if you can handle it) will hold the baby down, the nurse will prop up the tongue with q-tips or some other tool, then the doctor will go in with one or two snips, and then he or she will then cauterize it with silver nitrate if there is a lot of bleeding. When Julian had his cut, I was really shocked by the amount of blood, but the doctor assured me it was normal. He breastfed right after the procedure and the bleeding stopped after a few minutes. (His next poop was pretty black from all of the blood he swallowed.) There is a concern with this method that the doctor won’t cut enough (I’m sure it’s scary going into a little baby’s mouth like that with a pair of scissors, especially if they are screaming!) and there won’t be a full release, but we did not have this problem.
Laser Method – Some say that the laser method is superior because it can penetrate through more of the tissue for a more complete release and immediately cauterizes the wound, but it is not easy to find someone who will do this. (It takes a steady hand and a lot of skill.) Here’s a list of nationwide providers that will do the laser method.
Questions to Ask – If you have several options within your area, it might be a good idea to ask some of the following questions to narrow your search such as: 1) How often have you done this procedure? 2) How often do your patients come back for a revision? 3) What is the procedure like? 4) What are your thoughts on the scissor method versus the laser method? 5) What do you recommend for aftercare?

After Care

After the procedure, some say that doing exercises to help the muscles learn what they are supposed to do and to make sure the tongue tie doesn’t reattach and scar tissue doesn’t form is absolutely crucial. I personally felt that my son would strengthen his muscles by nursing and that the wound would be given sufficient time being stretched every time he cried. (I mean, I wish I could soothe him perfectly so that he never cried, but that has yet to happen.) To be honest, I felt like he had been through enough and I could tell he was in pain when I tried to do the exercises, and I just couldn’t bear to put him through any more. I can see how the lip tie would reattach if the lip continued to not to flange out while nursing, but I can’t imagine that the newly detached lip wouldn’t flange out. At any rate, you may want to rub a finger over the wound periodically to ensure that it doesn’t reattach.

Typically, babies feel discomfort for the first 24 hours after the procedure. Older babies and toddlers will typically feel discomfort for the first 48 hours. Breastfeeding and skin to skin are the best first lines of defense. Arnica is a good natural method for pain relief, or there’s acetaminophen (dosage should be given based on the child’s weight not age). Ibuprofen should not be given to children under the age of 2 months and topical numbing ointments containing benzocaine (Orajel/Anbesol) should not be given due to health risks.

After Julian’s procedure, he was in a considerable amount of pain for the first 48 hours. I ended up giving him some acetaminophen every couple of hours for the first two days and then periodically after that as needed. The wound was white for about the first 10 days and then it looked pink again. They say that with a successful tongue tie revision, you should be able to see a diamond shape. It was really hard to look under Julian’s tongue to see if this was the case but I could tell things were better based on our nursing relationship.

The Ideal Diamond Shape After a Tongue Tie Release (Photo credit: Ghahri, 2014)

We are now 6 weeks past our frenectomy date and I feel like I am finally noticing a difference. To be quite honest, he improved ever so gradually, that it was hard to notice on a daily basis, but when I reflect back to the way things were 6 weeks ago, it’s really a night and day difference. The clicking went on for some time until it finally faded away. He still pops off the breast during my let down from time to time, but that could just be due to my really powerful letdown. He is sleeping better and best of all, I am able to nurse laying down! He still wakes up to feed every 2-3 hours, but that is WAY better than every 45 minutes! At first, I really questioned whether or not getting the procedure was worth it (holding him down screaming, the needle under his tongue for the local, and the blood spurting as the doctor cut all we’re absolutely brutal), but now I am definitely glad we did it. I think that maybe we would’ve had a better experience had we found a pediatric dentist who could do the laser procedure, but that just was not an option for us.

Body Work

Some people recommend chiropractic or CrainoSacral Therapy both before and after the procedure to help release the muscles needed to nurse. CranioSacral Therapy (CST) is a gentle, hands-on approach that releases tensions deep in the body to relieve pain and dysfunction and improve whole-body health and performance. In her article, CranioSacral Therapy: When Can It Help, by Dee Kassing, BS, MLS, IBCLC, she states that,

“If there is misalignment and imbalance of the skull bones, this can affect the function of the palate, tongue, and other structures of the head. This can cause the palate to be too high or uneven, or the facial muscles to be too tight. Imbalance of the structures of the head, as well as trauma from the birth process itself, can cause constant irritation to the nervous system. This constant irritation may also cause hypersensitivity, which can sometimes be the underlying cause for babies who gag and cannot accept anything in the center or back of the mouth.”

We took Julian to get some CST before his tongue tie release when he was about 5 weeks old, and while it didn’t make breastfeeding better per sae, it changed him in both subtle and powerful ways. He always seemed to be just a little bit fussy, and afterwards he was SO CALM. I would definitely recommended CST for every infant after birth (But that’s another post!). I kept meaning to take him for some post CST, but the timing just never worked out. It is definitely something I would recommend to anyone getting a frenectomy. To find someone who does CST, you can call chiropractic offices that specialize in infants and see if they recommend anyone.

Happy Julian

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How to Identify and Deal with Lip Tie and Tongue Tie