Guest blog post by Del Smith who describes herself as a Mum of two teen boys, wife to one, International Board Certified Lactation Consultant (IBCLC) in private practice since 2007 and an Australian Breastfeeding Association (ABA) volunteer breastfeeding counsellor since 1999.

As I go to sleep I expect to dream about tongue and upper lip ties (TT and ULT)……they are a large focus of my life right now. I work as an IBCLC in Private Practice in Perth. I see a lot of Mums and new babies who are challenged by them, I still have a significant tongue tie myself at the age of 50 and both of our boys had them. And I must mention, my Facebook is filled with them daily.

So what is a tongue and upper lip tie?

Frena, frenula, frenum or frenulum is a length of tissue that holds or joins one part of our body to another. We all have them, in our mouth and other parts of our body. A “tie” is the common term that is used for those that are in the mouth. For some, the restriction caused by those lengths of tissue causes problems. Tongue and Upper Lip Ties are midline anomalies which occur along the vertical axis of the body. Midline anomalies can involve the brain, spine, heart, genitals and midline of the head and face.

When we are talking about the mouth you may hear the terms frenulum linguae or ankyloglossia (under the tongue) the frenulum labii superioris (inside the upper lip), the frenulum labii inferioris (inside the lower lip), and the buccal frena (inside the cheeks).

Research and anecdotal evidence are clearly showing the benefits of releasing these ties. They relate to how the restricted ties might affect breastfeeding, introduction of solids, airway development and function, digestive health, orofacial development, dental health, posture and pain, and speech development.

Internationally, there is a rapid increase in knowledge, expertise and treatment of these “ties” in the mouth. Unfortunately this also means that there is quite a lot of difference in opinion as some providers have not been able to keep up with this increase of knowledge and expertise. Definitions have been developed, diagnostic tools created, photos and videos are everywhere, treatments are being refined, and practitioners are very busy……and we are still learning how these ties affect us throughout our whole lifetime if they are left untreated.

I imagine by now you might have looked in the mirror or put your finger in your mouth or asked someone to look …..to find out if you have one or both…..or you may be wondering if your baby or child/ren have one or both. I have met many parents who didn’t realise they had them until I am visiting to assist with their little one’s breastfeeding issues. It’s common for more than one family member to have them. Many of us (me included) skipped through life with a TT and/or ULT without them seeming to cause any problems. I say “seeming” because with what I know now, I know I have not come through unscathed……..and I am soon to have mine released at the age of 50 years.

Statistics quoted vary widely – I’ve heard up to 15% quoted, some say more boys than girls. Professionals that work with babies are seeing more, a LOT more. We don’t know if the numbers are increasing or if the diagnosis has improved or both. We may have found a puzzle piece that we had not recognised was so important. And parents are learning and sharing more too. I feel part of the increase we are seeing is due to more parents passionately wanting to breastfeed their babies and are persevering to try and overcome problems if they have them.

What causes them to be restricted?….well, that is a whole other topic. There are a lot of people researching and discussing the possible reasons midline anomalies occur.

Tongue ties have been known about for a very long time (some of the oldest medical books describe tongue tie and their need to be released). There are very old stories of midwives having a sharp fingernail to release tongue ties soon after the birth.

Fifty years ago in Western Australia when I was born with a significant tongue tie, it was almost routine for the GP or midwives to release them soon after the birth. My Mums GP told her “Let’s just wait and see how speech goes”. However, there was absolutely no mention of an upper lip tie or how the tongue tie might cause other challenges. My guess is that the other consequences were not known by doctors at that time. Apparently my Mum was given tongue and speech exercises to do with me by the GP and my speech developed “normally”.

Upper lip ties and how they affect latching (breastfeeding, bottle feeding and finger feeding) are a much more recent realisation. A tongue tie and an upper lip tie both causing restriction often go together in the one individual. If untreated, upper lip tie restrictions can have ongoing significant impacts on feeding and dental health.

Even less is known about buccal and lower lip ties. We know some individuals have them but we are still discovering what effect they might have and if they require treatment.

I think the easiest way for me to explain to a person who does not have a tongue tie why it might be a problem, is to ask you to do a little exercise. Place the tip of your tongue right behind your front BOTTOM teeth, hold it there as best you can and then try and talk, swallow, hold your mouth closed, breathe through your nose, suck on a straw…….I think you will get the picture, it’s uncomfortable and it’s not efficient. We need to be able to lift our tongue up to the roof of our mouth even when our mouth is open wide, we need to be able to move our tongue around our mouth to move and remove food and liquids and to swallow. Swallowing is the beginning of the peristaltic movement along the digestive system.

And now the easiest way to explain the effects of an upper lip tie…press your finger over your top lip on top of your philtrum (that cute little dent). Now try and get your tongue up there, as if you needed to remove food from your teeth or under your lip. Now imagine you had both that tongue AND upper lip tie restriction.

Everything is connected……if one body part does not function as it should, the functions of many other parts will be affected.

How do you find out if your baby or any other family member has a tongue and or upper lip tie? Firstly you can look inside the mouth, secondly you can feel inside the mouth and thirdly you can discuss symptoms.

If you do a Google Image search “tongue tie infants” or “lip tie infants” you will find many pictures of varying degrees of restriction. It becomes fairly obvious when looking at the tongue tie pictures that there are different types of tongue shapes – some form a V at the front, some can’t lift up at all, some stay flat, some curl up a the sides and some cup up at the front…all of these can cause problems. With the lip ties you will see differences in how far the top lip can be flipped up, and how far down to the gum line the membrane comes and how wide the tie is…..many can cause problems.

Physical examination inside the mouth allows the amount of restriction to be felt. A simple sweep of a clean or gloved finger along the inside of the jaw under the tongue from right to left and under the top lip may allow a “speed bump” or line of tissue restriction to be felt. Sometimes the membrane under the tongue cannot be seen, but it can be felt, these are commonly called posterior tongue ties or submucosal ties. Two fingers can be gently pushed under the tongue on either side of this middle membrane, and often a tie may show for the first time.

The list of symptoms an individual may present with is long – symptoms may include:

Breastfeeding mother and infants: delay or absence of milk coming in, an infant who will not or cannot latch or maintain a latch, low weight gains, high weight gains, short feeds and frequent feeds, fatigue, gastro esophogeal reflux, vomiting, “clicking”, hiccups, distended stomach, nipple damage and pain, engorgement, blocked breast ducts, mastitis, over supply, undersupply, strong milk ejection reflex, breast refusal, suspected thrush, suspected food intolerance, no or slow milk ejection reflex, gut issues, poor sleep, biting/clamping, wind.
Older children and adults: difficulties with introduction of solids; TMJ; headaches and migraines; tightness of neck and shoulder muscles; speech concerns; airway concerns; dental issues such as gaps between top teeth or high palate, inability to clear food from the mouth, dental decay, formation of a normal shaped palate, swallowing issues, poor gut health, postural concerns.

If you are in the hospital with your newborn you are his/her advocate – you can be strong and stand up for him/her. Be determined and reach out to this fabulous community you have here who have “been there, done that”. There is no reason to wait until baby is attempting to latch to see if there are breastfeeding difficulties. If a tongue and/or upper lip tie is discovered it should be treated early.

Find the experts on examining for tongue and upper lip ties in the NICU and seek them out – it may be an IBCLC or a Paediatrician. And if they say no, don’t hesitate to ask for a second or third opinion. You may have to be very persistent. Ask “Why not have a look?” Ask “Why not release now?” “Please just satisfy my concern”. Ask if they have a tongue and lip tie policy and if they do, ask for a copy. If the person examining tells you there is a restricted tie, but recommends to “wait” or “wait and see” ask what your options are and what will be the consequences of doing or not doing each option. Especially ask about how not doing a release may affect the baby’s ability to breast/bottle or finger feed as soon as possible, and if there will be any impacts on airway development and gut health.

As soon as your baby is well enough for you to do skin2skin/bath/change/dress/cuddle/assist with feeds etc …….take a look for yourself, take a look. Raise it at a Care Meeting, as part of your baby’s care plan. If your baby is off tube feeds but not fully at the breast, ask about finger feeding or supplemental nursing system at the breast.

Upper lip tie and lower lip tie, showing both the before and after.

If you are already out of the hospital you may, from what you have been reading/seeing, suspect your baby or another member of your family has a tongue and/or an upper lip tie.

You will want to find a practitioner with expertise working with tongue and upper lip ties to do a thorough assessment and advise you on treatment options. An IBCLC (lactation consultant) with experience and knowledge of tongue ties and upper lip ties may be able to assess your breastfed baby/toddler and refer you on for a confirmation assessment and treatment. Release of TT and ULTs is not covered by the Scope of Practice of IBCLCs however. If you are an adult you will need to find a dentist, oral surgeon or an ENT to assess and treat yours. There is quite a lot of knowledge and experience (expertise) in the Western Australian parenting community and I think this is one of those times where it’s important to ask others about their experiences and for recommendations. In Western Australia we have paediatric dentists, paediatric surgeons, general dentists, GPs, Ear Nose and Throat specialists, and adult oral surgeons who all may agree to assess and treat tongue and upper lip ties. However expertise with tongue and upper lip tie restrictions is hugely varied amongst these professionals. I encourage you to call their practice and ask what their experience is with TT/ULTs. How many they treat in a week? Do they use LASER (light amplification by stimulated emission of radiation) or surgical scissors to release? Do they use anaesthesia? Do they treat both tongue and upper lip ties? Do they do assessments and the release procedure in the one appointment? What do they charge? You may choose a practitioner based on recommendation, distance you need to travel, how soon you can book an appointment, the cost, whether they treat both TT and ULT, or if they use laser over scissors……or a combination of all of these.

Some of the misinformation you may hear:

tongue and upper lip tie (restrictions) do not affect breastfeeding (or anything else)
tongue and upper lip ties (restrictions) will “naturally” be torn when a toddler falls and bangs their mouth
if baby can breastfeed, then it’s not a problem
if baby can bottle feed, then it’s not a problem
tongue and upper lip ties (restrictions) will stretch as the baby/child gets older
it doesn’t matter if you leave it til they are a lot older and then decide
tongue ties (restrictions) do matter, lip ties (restrictions) do not
if they bottle feed it doesn’t matter
if a baby/child/adult can extend the tongue beyond the lower gum there won’t be a problem
if speech develops normally, there is no problem

Before and after a baby has had a tongue tie and/or upper lip tie release there are therapies that may support optimal recovery and function. Different practitioners give differing advice on these so it’s important to do your own thorough research.

Bodywork or body therapies such as Chiropractic, Osteopathy, Cranio Sacral Therapy, Myofunctional therapy, Bowen Therapy and/or remedial massage are encouraged before the procedures and to assist with recovery after the procedures. You may be advised to massage and stretch the area that has been released to reduce the risk of reattachment. Skin to skin cuddling your baby is a normal part of nurturing your baby, please do it often. You may be advised to seek assistance of an IBCLC if the baby is breastfed or breastmilk fed. Some babies and children will benefit from suck, swallow and speech therapy, working with an experienced Speech Pathologist. And you may consider other therapies to aid yours and your baby’s physical (including gut health) and emotional health recovery.

The Australian Breastfeeding Association will be able to support you with ongoing breastfeeding information and strategies.

If your baby is still in hospital you may have limited access to these therapies. However, I encourage you to make enquiries inside and outside of the hospital as the more we ask the more we educate. And the more we educate, the more likely these therapies will become part of our regular treatment plans.

For me, linking all of this knowledge with breastfeeding began 18 years ago with the birth of our first son. He had a significant tongue tie and was born with “razor blades in his mouth!!” I was a member of NMAA (Nursing Mothers, now ABA) and had quite a lot of help with positioning and attachment. Eventually everything clicked at around 10 weeks and the razor blades disappeared. He continued to breastfeed until around 3 years of age when I was pregnant with #2. Our second was born late 1999 and sure enough there was a tongue tie again….he began breastfeeding easily and caused me no damage or pain. By then I was a breastfeeding counsellor with NMAA/ABA and thought I was proving that some babies could breastfeed with a tongue tie and not cause their mothers nipple damage and pain…..and he continued to breastfeed for the next 5 years. I previously told people that both boys had a tongue tie but they breastfed with “no problems”….I have since learnt that all of the breastfeeding challenges we had may have been caused by those ties that were not released – damaged nipples, over supply with one and undersupply with the other, over active milk ejection, fussing at the breast and refusal, reflux, colic, gagging, frequent feeding, minimal sleep, blocked ducts, blebs, engorgement, clamping/biting, wind. Obviously we can’t turn the clock back and do an experiment with their ties released soon after birth, but I had learnt enough about the possible long term health effects to make the decision to have their ties released during primary school. If I could turn back time, I’d be having them done as soon after birth as they were discovered.
There are many blogs and Facebook groups that parents and individuals can read/join to learn more about tongue ties and upper lip ties (and the other less known ones). I am very encouraged to see that some parents have become the experts and education advocates in this field. There is a thriving international community learning together, parents and individuals all the way through to the most highly respected professionals. It’s wonderful!

My aim in writing this article is to encourage parents to be informed and empowered to check for tongue and upper lip ties and have them assessed and treated early.

Dr Larry Kotlow http://www.kiddsteeth.com/articles.html
Dr Brian Palmer http://www.brianpalmerdds.com/
Dr Bobby Ghaheri http://drghaheri.squarespace.com/downloads/
FB: Tongue & Lip tie Support Australia https://www.facebook.com/groups/388958457911643/
FB: Tongue Tie Babies Support Group (international) https://www.facebook.com/groups/tonguetiebabies/
https://www.breastfeeding.asn.au/bf-info/tongue-tie
http://www.tonguetie.net/

Please don’t hesitate to contact me if you have any questions. You are welcome to e-mail delsmithlact@bigpond.com

Images used with permission from individuals and http://www.tongue-tie-education.com/tie-gallery.html

Such an informative article, thankyou Del! We would love to hear from you if you or your child has or had a tongue or upper lip tie. When was it discovered? Was it treated? Did it cause any issues? Please leave us a comment.