Signs of Tongue & Lip Ties in Babies and Toddlers
Tongue ties, lip ties, and even cheek ties (yes, you read that right!) are popular topics of conversation. Many people are asking “What is a tongue tie?,” “Can my baby have a tongue and lip tie?,” and “What are the signs of a tongue tied baby?”
Maybe you’ve heard something in passing in the hospital, on a Facebook mom group, or maybe you’ve even personally heard about ties at an appointment. Sadly there is a lot of misinformation out there with professionals throwing around phrases like, “your baby has a mild tongue tie, but don’t worry about it”, “ties can stretch on their own,” “they’ll grow out of their issues,” and then phrases on the other end of the spectrum like “we can just cut the tie and you’ll be good!” and “oh, getting a tongue tie procedure will fix all the feeding issues!”
Picture of frenula under tongue.
If you’ve been following Eat Play Say for a while, you know we strive to educate families on the root causes of potential issues and how to overcome challenges. Diagnosing tongue/lip/cheek ties based on looks alone is NOT sufficient, as function is what matters most. And claiming that something as simple a little “snip” of a tongue tie will fix all the feeding problems is problematic in itself.
So, our Speech-Language Pathologist, Feeding Specialist and Breastfeeding Specialist, Jessica, is here to tell you what you really need to know:
What is a Tongue Tie?
Tongue, lip, and cheek ties are pieces of tissue (frenula) made from collagen and/or muscular fibers that cannot stretch on their own.
Pause. Don’t we all have tissue under our tongue that connects the bottom of the tongue to the bottom of the mouth? Don’t we all have tissue that connects the lip to the gum line? So, do we ALL have tongue and lip ties?
No, no. This is important to understand. We do all have frenula. We do not all have lip and tongue ties. We have to look at function over all else.
The frenula impact how the tongue, lips, and cheeks move for sucking, swallowing, eating solids, and breathing. If they have great movement and good stretching abilities, no functional impacts should be observed. But, if they don’t have good movement and good stretching abilities, functional impacts while feeding will be observed. And it’s important to identify those functional impacts because the right muscle movements help the mouth and face develop to eat, speak, and breathe well.
What is a Posterior Tongue Tie?
A “posterior tongue tie” is exactly what it sounds like, the back of the tongue where it meets the floor of the mouth is tight and restricted. Essentially, a tongue tie that extends father back than normal is considered a “posterior tongue tie.” Signs and symptoms of a posterior tongue tie are similar to those of a tongue tie, and only a comprehensive evaluation will be able to determine if a posterior tongue tie is present.
What is a Lip Tie?
A lip tie is defined as a restriction in the tissue connecting the lip to the gum line. Remember all babies have tissue connecting their lips to their gums. It’s when that tissue is restricted and baby is experiencing functional deficits from that restriction that it is considered a “tie.”
Truthfully, there is not much research out yet about lip ties alone, as it is a subject area currently being researched. But, clinically, we’ve seen that it is rare for a baby to have a lip tie without a tongue tie! As a child gets older, a lip tie may have a “hooded” appearance, which can harbor bacteria and make tooth brushing uncomfortable. Some also state that lip ties can lead to gum recession due to excessive upwards pressure.
Many feeding challenges can occur due to both tongue and lip ties. Often, a lip tie is more heavily blamed for issues, while the tongue is actually what more greatly impacts baby’s ability to suck. This is why it is very important for a specialist to assess history, function, symptoms, and structure to help you determine the root cause of your feeding and oral rest challenges and properly assess for a lip or tongue tie.
What is a Buccal (Cheek) Tie?
Buccal ties are bands of connective tissue that connect the cheeks to the outer upper and lower gums.
Though there is very little established research about buccal ties, they may be restrictive for the functions of eating. (Baxter et al., 2014). Common signs and symptoms of a cheek tie are babies that have a hard time opening their mouth wide to latch, and babies who have poor cheek contraction for sucking- also called an inefficient suck.
Picture of frenula under lip.
Signs of a Tongue Tie
The signs of a tongue, lip, or cheek tie usually present as the following feeding issues, (Yoon et al., 2017):
Inefficient transfer of milk at the breast or slow bottle feeds
Spilling of milk at the lips
Clicking while sucking
Frequent gassiness or spit up that is not explained by an allergy
Milk left on the tongue after feeds
Mom’s nipples are cracked or bleeding
Baby has lip blisters
Breastfeeding is painful
Bottle feeding is difficult or feeds take forever
If the abovementioned symptoms are observed, it is important to seek out the support of a professional skilled in assessing oral-motor structure and skills- this could be a lactation consultant/counselor, speech pathologist, or occupational therapist. If you are breastfeeding, it is very important to have support from a lactation consultant/counselor who can assess the mother-baby dyad as a whole.
If your older baby or toddler is having issues feeding, breathing, or speaking, such as difficulties moving past purees or meltable foods, difficulties drinking from cups other than bottles, chronic open mouth breathing and/or drooling, and delayed and/or difficult to understand speech, it is important to seek out the support of a professional skilled in assessing oral-motor structure and feeding skills. A speech pathologist or occupational therapist trained in feeding could support you and should provide nearby referrals as needed for a dentist and/or ear-nose-throat doctor.
Is it Always a Tongue Tie?
Before we dive right into tongue ties, let’s address this. No. It’s actually not always a tongue tie. I know with social media, mom Facebook groups, and everyone talking about ties, it seems like any feeding difficulty just point right to tongue ties. And yes, that list of symptoms is long- so really that could mean that any baby with those feeding difficulties could have a tongue tie! But that’s really not the case. All of the babies who show the signs and symptoms of a tongue tie will not all have a tongue tie. Which is why jumping right to a tongue tie release is not the best course and is not something that is recommended here at Eat Play Say.
So, if it’s not a tongue tie, what could it be?
Feeding is a whole body experience. So if anything is “off” within the body, it can impact feeding. While yes, the frenula in the mouth is a giant part of feeding (and one could argue, the most important part), it’s not the only thing that can impact it. Many babies are born with body tension that can significantly impact feeding. Babies are really cramped in utero and therefore can become tight and stiff. Depending on their position in the womb they can have a side preference (where their head likes to lay to one side). Or their body can present asymmetrically at rest, where hips and shoulders aren’t lined up. If their body is tense, certain feeding/swallowing muscles can also be tense. If their body is uncomfortable, feeding can be uncomfortable, too.
On the opposite end, some babies are born with “low tone,” meaning that their muscles have less tension and less resistance to movement. This can make breast and bottle feeding difficult, as feeding is a hard and very intricate skill. If low tone is identified, often compensatory strategies such as offering jaw and cheek support while feeding and using specific feeding positions to help baby eat, can greatly help.
Sometimes even if body tension or low tone are identified and treatment for those diagnoses has begun, signs and symptoms of a tongue tie can still persist and impact baby’s ability to eat and move their mouth. For example, releasing some body tension might have decreased gassiness and spit up, but baby is still experiencing difficulty transferring milk efficiently or they are continuing to experience leaking of milk out the side of their mouth. If signs and symptoms are still present, then further evaluation is recommended, which may ultimately lead to a tongue tie release.
This baby’s hips and shoulders are not aligned in this picture. If this body positioning is observed frequently along with feeding difficulties, body tension may be present.
Tongue Tie Therapy
Now that we have also let you know that no, it’s not always a tongue tie, let’s start from the beginning.
If it is determined that your baby or child has signs and symptoms of tongue, lip, and/or cheek ties, your evaluating therapist should be able to support you through the process of pre-operative therapy and post-operative therapy. But like we said before, a tongue tie release is not always the best course of action or recommended, so it’s important to hit all the steps that are outlined below! An evaluating therapist may notice and observe tension patterns impacting jaw, head, and body movements, which can warrant a referral to a bodywork professional (physical therapist, occupational therapist, chiropractor, or professional trained in craniosacral therapy). This is where, as we said before, bodywork may relieve all of the signs and symptoms of a tongue tie! Or, it may resolve some of them and lead to further investigation on if a tongue tie release is warranted. They can refer you to a release provider and they also will help determine the right timing of frenectomy(ies) for your child and family, as it is a 6+ week process for most cases.
Getting a frenectomy (tongue/lip/cheek tie release) without therapy may not give you the results you’re looking for. Before and after the extra tissue is released, the tongue must learn how to move differently- this is where therapy matters.
Because the process of identifying a tongue tie can be confusing, we wrote out the steps to follow to ensure that you are receiving the best care (and ensuring that you are not receiving a release that is unwarranted, or a release too soon!)
The Process of a Tongue Tie Release
We’ve found the following “steps” work best to maximize results when a tongue/lip/cheek tie is identified:
Receive a functional oral-motor structural and skill assessment by an SLP, IBCLC, and/or OT.
Receive bodywork to assess and optimize tension patterns and movement by a physical therapist, occupational therapist, chiropractor, or professional trained in craniosacral therapy.
Receive a consultation with a recommended frenectomy provider for infants and/or children (usually dentist or ear-nose-throat doctor) if signs and symptoms persist after receiving oral motor and body work therapy.
Initiate or continue oral-motor (and whole-body) therapeutic exercises and have open discussions about progress with your therapist.
Determine whether or not frenectomy(ies) are warranted at this time, and if so, schedule the frenectomy(ies).
Complete the frenectomy(ies) and begin active wound care stretches as recommended by your release provider.
Continue oral-motor and whole-body treatment as recommended through and after the healing process (at least 4 weeks).
All in all, we see that the older the baby is, the longer they may need support, and this is simply due to the fact that they’ve been compensating and using less-than-optimal motor plans for a longer period of time. This is part of why, at Eat Play Say, we recommend asking questions early and seeking support as soon as your parent gut kicks in. If you don’t feel like your questions are being validated and answered, a second opinion from another provider doesn’t hurt. This isn’t a decision that is to be made quickly. It’s to be made after receiving education.
Research about Tongue Ties
The area of tongue ties, lip ties, and cheek ties is still being researched. It’s a relatively new area and what is being seen in clinical practice is driving current research studies. While anecdotal evidence is not a very strong form of evidence, it’s important to remember that clinical practice is where research begins. There is not a lot of strong research supporting that oral ties should be released. And to be frank, many providers in the past (and even currently) have jumped right to releasing ties without recommending therapy before and after the release. Therefore, sometimes outcomes aren’t always as good as they could be. This is why reading this blog and making sure parents understand the entire process, as well as realizing that like everything in life, releasing a tongue tie is not a one-size-fits-all procedure is important!
Do tongue, lip, and cheek ties stretch on their own over time?
No, the frenulum of the tongue, lips, or cheeks are made of connective tissue, collagen, and sometimes combined with muscular fibers. They are unable to stretch on their own. The tissue around the frenula can soften and increase in mobility, but the frenulum itself will not stretch on its own (Mills, 2019).
Do the issues associated with tongue/lip/cheek ties correct themselves over time?
While the symptoms associated with ties can change, we often see them compound over time. It’s important to know that the body wants to do what is easiest, so that is where compensations form (like mouth breathing, sticking to soft or meltable foods, sleep disordered breathing, etc). Knowing the root cause of your baby or child’s oral motor issues is part of making an informed decision about how to move forward! (Ghaheri, 2016).
Are tongue/lip/cheek ties new and overdiagnosed?
Restricted frenula have been recognized and treated since the Middle Ages to help with feeding and speech. Prevalence of tongue ties is estimated to be around 8% (Hill et. al. 2021), but this may not fully take into account posterior lingual restrictions. Controversies have been present regarding who should treat and release ties, along with the effectiveness of frenectomies. Despite availability of several assessment measures, there still is a lack of consistent, standardized assessment among medical professionals. The best way to assess the root cause of feeding difficulties is involving multiple, trained professionals reviewing medical history and observing the infant at rest and while feeding.
Regarding overdiagnosis- if we aren’t catching ties accurately enough, there may be under and overdiagnosis happening. We do know that often, a frenectomy alone is not enough to create long-term changes in functional movement. Clinically, we are seeing great success with ensuring mom and baby get support, along with a combination of pre- and post-operative therapy that focuses on the whole body, as feeding is a whole-body task.
Do tongue ties only affect breastfeeding? Not bottlefeeding?
While most research supports that addressing tongue ties can reduce maternal pain and improve breastfeeding efficiency, we clinically see that tongue ties can impact the quality and control of sucking, which can impact bottle feeding. We also see that bottle feeding can “mask” a tongue tie’s true impact, especially when using a bottle that relies on a shallow latch and compression. If your baby has excessive gassiness, clicking/loss of suction, leaking of milk t the lips, milk residue on their tongue after feeding, chronic spit up, or uncoordinated bottle feeds, it’s important to get a full structural and function assessment by an IBCLC and/or therapist (SLP, OT). There is research to show that bottle feeding skills improved post frenectomy. (Ghaheri et al., 2022)
Who are the Tongue Tie Specialists?
We have heard this scenario thousands of times, so we want to address it:
“My pediatrician is not concerned about my child’s oral structure and symptoms (chronic mouth breathing, feeding issues, speech issues, etc). Does that mean there is nothing wrong?”
If your gut is telling you there’s more going on, it’s always better to investigate the “why”. Pediatricians are an excellent source of information for medical needs; however, they have limited time with your child and should refer out to specialists to provide a more thorough assessment in cases where feeding concerns are present and signs of a possible tongue tie are also present. A proper evaluation should explore your family and your child’s history (medical, gastrointestinal, airway, etc.), oral motor development, fine and gross motor development, feeding skills from birth, speech and language skills, and even diet. Providers will then refer out and work with you to support your child’s orofacial and speech-language development.
As a reminder, providers who are appropriate to discuss tongue ties with you are:
International Board Certified Lactation Consultants (IBCLC)
Speech-Language Pathologists trained in oral motor/feeding/oral ties
Occupational Therapists trained in oral motor/feeding/oral ties
Physical Therapists trained in oral motor/feeding/oral ties
Cranial Sacral Therapists trained in oral motor/feeding/oral ties
Pediatric Dentists trained in oral motor/feeding/oral ties
Pediatric Otolaryngologists (ENTs) trained in oral motor/feeding/oral ties
Tongue Tie Releases are Not One-Size-Fits All
We know that navigating tongue ties can feel very overwhelming. We have included a Bonus Guide in our Infant Feeding Handbook for parents who may encounter feeding difficulties and need to receive assessment and treatment for oral ties. Make sure to gather as much information as you can and trust your gut entirely! It is never wrong.
Sources:
Ghaheri BA. 2016. Breastfeeding Compensations for Tongue Lip Tie Are Problematic. https://www.drghaheri.com/blog/2016/6/23/breastfeeding-compensations-for-tonguelip-tie-are-problematic
