What Is Tongue Tie?
Tongue tie, or Tethered Oral Tissue (TOT), also medically known as ankyloglossia, is commonly overlooked and often misdiagnosed.
Lingual Frenulum is a condition found in babies at birth where a band of tissue at the end of the bottom of the tongue remains attached to the floor of the mouth, restricting movement of the tongue.
The visible membrane under the baby’s tongue that can restrict movement of the tongue is called an anterior tongue tie, or sometimes a classic tongue tie.
Potentially, tongue tie can affect an infant’s ability to stick out their tongue, breastfeed, swallow and eat and talk when they are toddlers.
Typically, the lingual frenulum separates before birth; however, in some cases, this does not happen, leaving the infant and mother with a variety of possible issues.
Many mothers are unaware of tongue tie and cannot understand why feeding their baby is so difficult and many lose their milk supply. What do mothers need to know?
Symptoms of Tongue Tie
Parents may not realize that it is not normal for babies to sputter, choke, gag, vomit, click, spill milk, have reflux or arch at the breast no matter how well they are growing.
The symptoms listed below are a strong indication that the baby is under stress, often due to untreated tongue tie. Here are some possibilities:
What breastfeeding infants may exhibit:
- Poor latching on to the breast
- Falling off breast easily
- Gumming or chewing the nipple while nursing
- Inability to hold a pacifier or bottle
- Clicking sound while nursing
- Gassiness, reflux or colic (swallow air because they cannot maintain suction)
- Excessive drooling
- Hypersensitive gag reflex
- Inability to drain the breast
- Persistent swallowing deficits
- The end of the tongue may be heart shaped
- Gagging or choking on milk and pops off breast frequently to grasp for air
- Poor weight gain
- Failure to thrive
- Falling asleep during feedings, them waking a short while later to nurse again
- Inability to coordinate suck-swallow-breathe
- Sleep deprivation due to the need for frequent feedings
- Extended nursing episodes
- Biting – babies have trouble grasping the nipple and bite to hold on
- Improper tongue mobility that prevents babies from clearing milk from the mouth, causing tooth decay especially in the front teeth
- Painful latch once upper front teeth erupt
- Continued hunger after 20 minutes of sucking on the breast
- Possible open mouth posture associated with imbalance in skeletal structure
- Possible difficulty with mouth opening, latch and tongue movement
- When baby cries, the tongue may lie flat in the bottom of the mouth (baby’s tongue should elevate when they are crying)
- White coated tongue (thrush)
- Palatine tori (or boney development in the center of the hard palate)
- Gap between teeth and jaw issues
What breastfeeding mothers may experience:
- Extremely sore nipples with a flat crease after baby has attempted to eat
- Possible plugged ducts, mastitis, breast and nipple pain, engorgement
- Low milk supply because baby is unable to stimulate milk supply with proper sucking
- Discomfort while nursing
- Early weaning due to painful nursing; baby gets frustrated
- Cracked, bleeding and sore nipples
- Sleep deprivation because baby is nursing more frequently, up to every two hours
- Nipple blanching and vasospasm (constriction of blood vessels in breast)
- Anxiety, stress and fatigue
- Post-partum depression
- Slow weight loss from pregnancy
- Feelings of guilt and failure
What toddlers or older children may exhibit:
- Delayed speech development or deterioration in speech
- Speech impediments
- Picky eating
- Gagging, choking or vomiting foods
- Inability to chew appropriately solid foods
- Poor swallowing
- Risk of anterior open bite
- Dental hygiene issues such as dental decay or poor oral hygiene
- Large gaps between front teeth
- Aesthetic problems
- Mouth breathing
- Propensity to allergies
- Highly arched palate with consequent narrowing of airways with the potential sleep apnea or sleep disordered breathing patterns
- Open-mouthed posture associated with an imbalance in skeletal structural
- Low-tongue posture, which may contribute to sleep disordered breathing and sleep apnea
- Restricted dental arch and facial development
- Behavioral problems such as biting peers due to discomfort and as a coping mechanism
- Loss of self-confidence because they sound different
- Strong, incorrect habits of compensation being acquired
- Constant state of stress
Other possible related tongue ties and restrictions:
- Lip tie and upper lip tie (maxillary labial frenum):
- Difficulty with lip flanging
- Decreased jaw opening
- Air swallowing
- Fussiness after eating
- Excess gas
- Gingival recession
- Maxillary midline diastema (gap between top front teeth)
- Buccal tie:
- Difficulty with jaw opening
- Difficulty with lip flanging
- Compensation of facial muscles
- Posterior tongue tie:
- Difficulty feeding
- Speech issues
What Your Doctor May Tell You About Tongue Tie
Your child’s pediatrician may tell you that the cause of tongue tie is unknown and that why it happens is not clear.
The doctor may tell you that most often the frenulum (band of tissue) under your baby’s tongue gradually stretches, and therefore, may resolve the problem.
It may be that your pediatrician is not familiar with tongue tie and therefore, will refer you to an ear, nose and throat specialist (ENT), oral surgeon or dentist.
The ENT, oral surgeon or dentist may inform you that tongue tie can affect the baby’s oral development because of the way they may eat, speak and swallow; therefore, it is necessary to do surgery.
In the case of a tight frenulum, the ENT, oral surgeon or dentist may recommend surgical treatment to prevent eating and swallowing problems.
This surgery consists of separating by cutting the band of tissue (frenulum) in a procedure called a frenuloplasty.
The ENT, oral surgeon or dentist may also suggest a frenectomy, which is the removal of a frenulum (like a frenulosplasty) or a frenotomy and frenulotomy, which is cutting without the removal of tissue.
If there are no feeding problems and the frenulum does not stretch by the time your child is 10 to 12 months old, then the ENT, oral surgeon or dentist may recommend surgery so that speech problems do not occur.
The doctor may tell you that the surgery is a very quick and painless procedure.
Another Way of Thinking About Tongue Tie
Tongue tie is more common in boys and runs in families.
According to researcher Ben Lynch ND, one of the causes of tongue tie is the genetic mutation MTHFR.
The MTHFR defect in the methylation process means that the body is unable to excrete toxins and pathogens very efficiently due to reduced glutathione, which is the master antioxidant in the body.
If your child has the MTHFR mutation, it is best to provide nutrient support for the methylation process.
It has been found that the most effective way to support your child’s methylation process may be through the skin, where there is maximum absorption of nutrients.
Lack of appropriate screening:
Tongue tie is often misdiagnosed and very poorly understood.
Alison Hazelbaker, PhD, who designed the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) states that:
“Part of the problem is the lack of appropriate screening for the condition. There is only one screening tool for tongue tie that has been proven through scientific research to accurately identify tongue tie in babies – the Assessment Tool for Lingual Frenulum Function (ATLFF), which evaluates functional and appearance aspects of the baby’s oral anatomy.”
“Simply looking under a baby’s tongue or pressing back against the baby’s tongue base will not render an accurate diagnosis.”
According to Dr. Lawrence A. Kotlow DDS, PC, the foremost expert on tongue tie in the United States:
“Correct examination of infants requires the infant be placed on the examiner’s lap with the infant’s head facing the same direction as the person evaluating the infant and the infant’s feet facing away from them. Just looking at the frenulum in the mother’s lap will most likely lead to an incorrect or missed diagnosis.”
Effect on digestive system:
The tongue is the beginning of the digestive system.
The digestive system, gut health (microbiome), enteric nervous system and breastfeeding are all connected.
The enteric nervous system governs the gastrointestinal system, which includes the digestive system. It is known as the “brain in the gut”.
The gastrointestinal microbiome is connected to the brain from the vagus nerve; this connection is known as the gut/brain connection.
The microbiome is the hub of trillions of micro-organisms that protect our immune system. It is the “hard drive” of the body.
Healing the microbiome and the gastrointestinal system begins with:
- Making lifestyle changes
- Addressing nutritional deficiencies
- Eliminating toxins
- Eliminating pathogenic parasites, yeast, fungi, viruses and bacteria
- Overcoming allergies
- Treating failure to thrive or slow growth
- Integrating home remedies
- Holistic practices
Healing the mother, healing the baby:
Breastfeeding problems have been found to be related to the internal terrain of the mother.
Maternal gut health affects the baby’s gut integrity.
When there are microbiome deficiencies and an unhealthy gut, enteric nervous system imbalances, and pro-inflammatory responses from the immune system, then a cascade of disease processes starts to unravel in the body.
The well-being of mothers may be compromised by:
- A mother’s:
- Post-partum depression
- Food allergies
- Milk supply
- Polycystic Ovarian Syndrome (PCOS)
- Thyroid status
- A baby’s:
- Tongue tie
- Acid reflux
- Needy infant behavior
- Slow growth
- Failure to thrive
- Breastfeeding difficulties
To Clip or Not to Clip?
In some cases, therapy intervention may not be enough depending on the severity of the tongue tie of your child.
Is surgery your child’s best option?
Alison Hazelbaker PhD says: “As guardians of our babies, all parents and health care providers need to be sure that the benefits of any surgical procedure outweigh its risks. Our vulnerable babies depend on us to do so.”
Many experienced breastfeeding experts around the world are deeply concerned about the huge numbers of babies receiving laser treatments, some possibly unnecessary.
According to Dr. Hazelbaker: “Dentists’ tongue tie clinic waiting rooms are full of mothers and babies every day, lining up to have their babies’ “ties” released. Unfortunately, many of us are left picking up the pieces of shattered breastfeeding relationships where the surgeries were unhelpful, and in fact, destructive to breastfeeding.”
To be certain on what is fact and what is myth on tongue tie, Dr. Hazelbaker clarifies this information for parents in her page about modern myths about tongue tie.
Possible alternatives to surgery:
Pediatric Myofascial Release
It is possible that some tongue tie cases can avoid tongue tie surgery by doing pediatric myofascial release.
The fascia are the tissues that hold muscles, bones and joints in place.
In many cases, especially in the case of physical trauma – even birth trauma – the fascia become stiff and contribute to misalignment.
This type of therapy is an easy, safe and effective therapy designed to be combined with exercises, flexibility programs, neurodevelopmental treatment in conjunction with sensory integration and movement therapy.
This type of therapy is based on exercise treatments pertaining to oral and facial muscles that relate to breathing, swallowing, chewing, speaking and tongue placement.
If you are having trouble breastfeeding, consult with an IBCLC lactation consultant, La Leche League support group or midwife.
According to Dr. Alison Hazelbaker, there is no scientific evidence to support severing buccal ties to aid sucking.
In fact, buccal ties play a major role in breastfeeding by assisting the vacuum required to maintain an effective latch.
Their size will naturally reduce with maturation changes as the baby grows through childhood.
Upper Lip Tie
In most babies (93.3%) the upper lip (labial) frenulum looks exactly like the images which dentists refer to as an upper lip tie.
According to Alison Hazelbaker PhD, there is absolutely no scientific evidence to support the severance of the upper lip frenulum to assist with breastfeeding.
Unlike the tongue frenulum, “the upper lip frenulum changes over time with growth and development. The frenulum gets smaller, thinner, and will insert higher up on the gum line as the teeth erupt. By the time a child has permanent teeth, the upper lip frenulum looks nothing at all like it did during infancy.”
As suggested by Dr. Hazelbaker, breastfeeding should not be overlooked and every attempt possible should be made to get your baby to breastfeed.
Bowman therapy is a special technique that works on the cranial nerves and muscles that affect digestion and breastfeeding movements.
This therapy works to restore a baby’s nervous and fascial system.
Beckman oral motor therapy
This type of therapy is for children with impaired oral motor skills who are not able to follow a command for oral movement.
There are nearly 5,000 Beckman Oral Motor trained professionals, many of whom are speech/language pathologists, so you may be able to find someone near you trained in this therapy.
Complications of tongue tie release:
Surgery can result in the following:
- Failure to fully release attachments adequately, often releasing only a portion of the tongue tie, resulting in additional surgery; this is quite common.
- Increased discomfort and fussiness post-surgery
- Increased potential for bleeding during and after surgery, especially when revising posterior tongue tie and lip ties
- More collateral damage and post-surgical edema and swelling
Not all tongue ties and lip ties need surgery, but for those that do, laser surgery is a choice for your baby.
Laser treatment is a safer choice rather than scissors for the following reasons:
- No need to place infant under sedation or in an operating room
- Bactericidal: virtually no chance of infection
- Reduced post-surgical swelling, pain, discomfort
- Significantly reduced risk of any bleeding
- Procedure takes less than 2 to 3 minutes in the dental office
- Infant is away from mother for less than 10 minutes
- More precise surgery
- Safe, quick and void of any known complications if it is done by properly trained and experienced laser surgeons, using proper recommended safety precautions (such as laser safety glasses on everyone in the surgical area: child, surgeon and staff)
- No known contraindication for frenum laser surgery in a normal healthy infant
- No chance of any allergic or drug reactions for the baby because no medications or drugs are used
- Infants are not required to be without nourishment for hours prior to or after surgery, although it is requested that infants do not nurse for at least 90 minutes prior to surgery, since as soon as surgery is completed, the infant is returned to the mother to nurse and a hungry infant is more likely to go to the breast quickly
Consult with your doctor about what is best for your baby or child.
Aftercare of tongue-tie or lip-tie release:
Epidemic Answers does not condone the use of Tylenol (acetaminophen, paracetamol) because it has been shown to reduce glutathione, the body’s master antioxidant, and has been linked to the epidemics of autism and attention-deficit disorders.
In addition, we do not condone the use of ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs) because they disrupt the gut microbiome, potentially skewing it in an unhealthy direction.
Because babies do feel pain and discomfort, we recommend pain management from other sources such as:
- Homeopathic remedies such as:
- Bach flower remedies such as Rescue Remedy, which is used for trauma and anxiety
- Schuessler’s cell salts
- Infusion relaxing tea:
- 2 parts chamomile, 1-part catnip and 1-part passionflower: Put herbs in pint jar until jar is ½ full. Boil water and pour over dried herbs in jar. Put lid on. Let sit for 4 hours minimum. Strain herbs and compost them. Sweeten infusion with stevia. Store in refrigerator and use as needed.
- Tongue-tie salve, an herbal salve on breasts each time after baby nurses
- Combine 1 ounce of coconut oil, 2 ounces of olive oil, beeswax, 1 tsp. whole cloves, 1 tbsp. calendula flowers, 2 tbsp. yarrow (add more olive oil if needed) in a jar and put the lid on. Place the jar on a dishcloth in a crock pot. Add water until it comes to 1 inch of the top of the jar. Let it heat on low heat for 3 days. Add more water as it evaporates out. After 3 days, strain your herbs and put your oil in a saucepan over low heat. Add in a small amount of beeswax and mix until it melts. Test a bit of your oil on a cool surface to see how hard it gets. You want it to be the consistency of soft vasoline. Add more beeswax if you need it to firm up more or more olive oil if you need it to be softer. As soon as the consistency is right, pour your liquid in a jar or a 2-oz. tin and let it sit to firm up.
Tummy time is an important step after tongue-tie or lip-tie release.
Tummy time plays a vital role in the baby’s development as well as the structure of the neck, throat and tongue rehabilitation in the before and after a frenectomy.
Tummy time is the position that offers the maximum amount of range of motion for the tongue.
It helps to untuck the tongue and chin, helps extends the neck and lengthen shortened tissues which affect tongue function.
Any cranial compression or low vagus nerve functioning can also be addressed by tummy time.
Stretching Massage Exercises
Lawrence Kotlow DDS says that properly stretching and massaging the frenulum area for at least 10-14 days can prevent the areas from growing back together.
Frenectomy exercises are especially important if your child has had surgery to remove the tongue tie.
Coconut oil can help with these massages.
Breastfeeding is the most effective way to encourage effective sucking in your infant after a tongue-tie release.
stimulating the ‘heart point’ on the hands of the baby is helpful for Tongue-Ties because the stimulation helps relax the area.
Body work can help improve recovery and overall oral function of your baby, structural misalignments due to birth trauma, cranial compression and low vagus-nerve functioning.
It is advisable to do bodywork pre- and post-surgery; some body work therapies are:
- Craniosacral therapy
- Osteopathic manipulation
- Myofascial release
- Myofunctional therapy
- Bowen therapy
Putting your fingers in ice water prior to doing massage exercises on your baby’s mouth can help ease the pain from surgery.
Checklist for Tongue Tie
Healing the mother’s gut is integral to successful breastfeeding.
Here are some of the dietary changes that can help initiate change for both the mother and the baby:
Check your breastmilk supply:
Some women use a nipple shield to alleviate the pain of breastfeeding from cracked nipples and sore breasts; however, it can reduce the amount of breastmilk supply to baby if not applied properly.
Check with your lactation consultant, pediatrician, midwife or doula to make sure your supply of milk is not limited.
Make dietary changes:
Babies and toddlers need a diet high in protein, high fat, complex carbohydrates and no refined white sugar/flour, lots of vegetables, leafy greens and some fruits.
- Avoid PediaSure because it is high in sugar, contains synthetic vitamins that are not in a bioavailable form, and contains food dyes and genetically modified (GMO) foods
- Eat whole foods
- Buy organic foods
- Remove all GMO foods
- Remove all fast and processed foods
- Remove all foods with:
- Artificial colors
- Artificial ingredients
- With an elimination diet, remove potentially inflammatory foods such as:
- Strictly limit:
- Refined salt
- Refined carbohydrates
- Consider implementing the Feingold diet to eliminate preservatives, artificial colors and artificial flavors from your child’s diet.
- Try protein shakes and smoothies for toddlers and add predigested protein (collagen) called Arthred by Allergy Research Foundation or Nutricology to increase muscle tone and protein.
- Supplement with iron-rich foods such as:
- Nut butters
- Leafy greens such as:
- Turnip tops
- Black strap molasses
- Pumpkin seeds
- Sesame seeds
- Sweet potatoes
- Add vitamin C sources (such as strawberries, citrus fruit and cruciferous vegetables) to increase iron absorption.
- Supplement with zinc-rich foods such as:
- Whole grains
Include plenty of good quality fats:
Babies’ and toddlers’ brains needs lots of fats.
The following nutrient-dense fats can be added to baby’s formula and given with solid foods for toddlers:
- Coconut oil
- Cold-pressed extra-virgin olive oil
- Wild salmon
- Organic chicken
- Organic turkey
- Grass-fed ghee or butter
- Organic eggs
- Essential fatty acids from:
- Cod liver oil
- Hemp seeds
- Flax seeds
- Evening primrose oil
- Borage oil
- Walnut oil
- Krill oil
Remove vegetable oils such as:
Heal the gut with special diets that focus on removing grains and reducing sugars, fructose and starchy carbohydrates, such as:
- GAPS (Gut And Psychology Syndrome) diet
- Body Ecology Diet
- Paleo diet
- Modified Atkins diet (replaces the ketogenic diet)
Learn more about healing diets and foods.
Add fermented foods and probiotics daily:
These will keep the gastrointestinal system and microbiome healthy and strong which in turn will keep the immune system strong.
- Eat kefir yogurts
- Eat fermented vegetables
- Eat umeboshi plums (very alkalizing)
- Eat miso soup, if soy is tolerated
Some good probiotics are:
- Gut Pro
- Dr. Ohirra’s Live Cultured Probiotics
- Garden of Life
- Klaire Labs
Use digestive aids with your practitioner’s guidance:
- Betaine hydrochloric acid (HCl) for low stomach acid (with meals)
- Digestive enzymes with DPP-IV for gluten and casein intolerances (with meals)
- Proteolytic enzymes (on an empty stomach)
- BiCarb (on an empty stomach)
- Bromelain (with meals)
- Papaya (with meals)
Ask your pediatrician to run some laboratory tests for:
- Possible food sensitivities and allergies
- Enzyme-Linked Immunosorbent Assay (ELISA) IgG, IgA, IgE and IgM
- Nutritional deficiencies in vitamins and minerals. The NutrEval by Genova Diagnostics Labs covers the following areas:
- Cellular energy
- Mitochondrial metabolism
- Neurotransmitter metabolism
- Vitamin deficiencies
- Toxin exposure
- Detoxification need
- Bacterial and yeast overgrowth
- Gluten and casein sensitivities
- Organic acids: The organic acid test by Great Plains Laboratory for:
- Yeast overgrowth (Candida)
- Other microbial infections
- Comprehensive Stool Analysis by Genova Diagnostic Labs to identify:
- Altered gastrointestinal function
- Bacterial/fungal overgrowth
- Chronic dysbiosis
Always observe the color and consistency of your baby’s stool, which tells the story of the state of the gastrointestinal tract.
Stools should not be green or yellow with mucous and runny. If they are not normal, then ask your doctor to run some of the above tests.
Further testing for failure to thrive may also be useful:
- Thyroid function
- Ferritin levels
- Lead levels
- Iron levels
- Liver enzymes
- Ammonia levels
- Lactate levels
- Pyruvate levels
- Sweat chloride test
- Urine organic acids
- Serum amino acids
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Sources & References
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Baxter, R., et al. Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. Intl Journal of Clinical Pediatrics. 2018 Sep,7(3):29-35.
Berry, J., et al. A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeed Med. 2012 Jun;7(3):189-93.
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Ghaheri, B.A., et al. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 2017 May;127(5):1217-1223.
Ghaheri, B.A., et al. Revision Lingual Frenotomy Improves Patient-Reported Breastfeeding Outcomes: A Prospective Cohort Study. J Hum Lact. 2018 Aug;34(3):566-574.
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Hesselbacher, S., et al. A Study to Assess the Relationship between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Adults. Cureus. 2019 Oct 24;11(10):e5979.
Hogan, M., et al. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. May-Jun 2005;41(5-6):246-50.
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Baxter, Richard, et al. Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. Alabama Tongue-Tie Center, 2018.
Academy of Applied Myofunctional Sciences
Academy of Orofacial Myofunctional Therapy
Breastfeeding USA: Tell Me about Tongue Ties
Feeding, Speech and Mouth Development with Diane Bahr
International Affiliation of Tongue-tie Professionals
International Board Certified Lactation Consultant (IBCLC)
Lawrence A. Kotlow DDS, Pediatric Dentist
The Mommypotamus’ Guide to Identifying Tongue and Tongue/Lip Ties
Mouth Development: From High and Narrow Palate to Buccal and Tongue Ties
Post-Surgery Stretching and Massage Video by Lawrence Kotlow DDS
Tongue-Tie and Lip-Tie Support Network
What to Expect After Tongue-tie and Lip-tie Release
Tongue-Tie Support Groups for Parents:
Tongue-Tie Babies Support Group
Tongue-Tie Babies Facebook Group