Tongue ties, lip ties! Oh my, my baby has what?

In short, no pun intended, “ties” are tight skin/tissue adhering the tongue to the floor of the mouth too tightly, which can make the tongue appear short (but not always...tongue ties are sneaky), or skin/tissue under the upper lip attaching to the gums...and even in the cheeks adhering to the gums. These ties can cause issues for breastfeeding, so as you can imagine, I have much experience as an International Board Certified Lactation Consultant (IBCLC). I might be the first person to start a conversation with a family about this concern or they might call me because someone else has questioned it.

I help families achieve their own visions of success for their unique issues and concerns, offering support and solutions specific to them.

As a functional concern, tongue/lip ties can take time to show they might be causing a concern, so after a few tries or a few days of breastfeeding before we suspect an issueA question I get asked a lot is “Why didn’t the hospital catch it?” The answer to this is that tongue/lip ties are more of a functional issue and not a structural defect. So, for something like a cleft palate, that is a structural, obvious concern. That is going to be noticed and acted upon quickly in hospital. 

Our hospital stays are too short to catch the tongue/lip tie concerns. Another variable is that common birth practices in our society right now can mask or mirror the same concerns that would signal a tongue/lip tie issue. It can take some investigation and skill to sleuth out what is what and know confidently the issues are related to ties. 
Why does it seem like there are so many ties these days? I am not a researcher but rather a clinician so I am not involved in looking at what “might” be causing it (is it an external force or is it just always been this way) but rather dealing with the management of them. I will say, I have been in a breastfeeding helping role for 13 years and it is a subject that is brushed over in trainings of all sorts. I was an IBCLC for a couple years before I found myself in deep conversations about them - and if you know anything about becoming an IBCLC - there is a lot of training, education and exam taking...so a lot of opportunities to learn and to learn from different sources. I was NOT taught in any of my training how to do a proper infant exam. How crazy is that? That someone can become an IBCLC without learning how to do proper visual exam and functional exam. Once I learnt this skill I added it to my assessments, I began to observe and learn significantly more about infants oral structures. Do I see more tongue ties now than I did before then? Of course, I do. But I wasn’t looking for them before. We are taught that ONLY a heart shaped tongue, tissue right to the tip of the tongue and likely not latching, is a tongue tie. And that they are also not common at all.  This is why I also say you cannot see just any IBCLC and if you see one IBCLC and you are not getting the results you want, get another one. IBCLCs are not all created the same. All while this is happening and professionals are learning more, families are learning more about breastfeeding but also COMMITTING to breastfeeding. This means that when they have trouble, they are reaching out and saying “help me”. That means our population of babes to check for ties has gone up so of course we are going to see more. In previous times, these families would have said “I tried breastfeeding but it didn’t work”. Researchers are working on the questions of why are human babies born this way.  It sure would seem like the human race is setting itself up for failure as a species with how hard breastfeeding has become.
Who is the right person to see for tongue/lip ties and what are the steps after a diagnosis? Truthfully, I am biased in this. Maybe not biased but I am being aware of how my answer will be seen to others. I believe strongly the first stop needs to be a skilled IBCLC. There are so many reasons for this but with years of working with families with ties, I want to be able to set a plan for success up for families. This means all the steps and expectations are on the table, that before any treatment takes place, the parents know what it looks like, what to expect and how important a proper process is for success. Some plans are designed to fail and then it can leave the families more frustrated than they were with concerns. 
Let us think for a few minutes about what complaints we hear about breastfeeding…I will make a really short list just as an example:

• Sore nipples/breasts
• Low supply
• Babies are not gaining, slow gaining
• Colic
• Babies are not sleeping
• ​Lack of stool

All of these can be signs of a tongue/lip tie. But they can also be 10 other things. If someone’s first stop is a dentist or an ENT are they going to get a full assessment of breastfeeding to rule any other the possibilities conclusively? Not a chance. That is actually setting them up to fail. What has to be addressed before a revision is proper breastfeeding technique, supply, weight and anything else we can identify as an issue. Take a family with a low weight baby, with a mother who likely now has a low supply in response, and put the demands of getting babies weight up, a mothers supply up and add aftercare of a frenectomy onto their plate - that equals a recipe for stressed out *everyone* and no resolution, perhaps quitting breastfeeding and postpartum mood disorders. And yes, I said “after care” - if you have a provider who tells you you don’t have to do anything after a tongue/lip tie revision - go somewhere else. But honestly, what if it is just bad breastfeeding technique causing the issues? Who is assessing that in the ENT’s or dentist's office? There is so much improvement can be made with technique overall that can improve a lot of breastfeeding concerns. So, I start at basics.  After that, I help people find their next appropriate care provider - based on their specifics. 
I mentioned mothers health playing a factor - maybe there are indicators that her own health is impairing milk supply. Babies respond to flow and without that flow, they also don’t want to try and improve anything. Add in a tongue tie and they just don’t care to breastfeed nicely. If supply is low, again even with a revision, they just are not happy breastfeeders. Then we have people saying “the tongue tie wasn’t the issue” and sometimes add in that “they did the procedure for nothing”. Or because intake is low they supplement, babies stops breastfeeding and everyone says “it is because you gave a bottle”. I make plans to not only increase supply, but supplement in a manner that breastfeeding still works.
We also need to know that the baby is healthy enough and strong enough for a revision. By that I don’t mean babies have to be 7 lbs or some random weight. I mean where are they in regards to their expected weight gain. Maybe they are not gaining weight, maybe they are gaining weight, but slowly - so maybe a baby that isn’t back to birth weight at 2 or 3 weeks yet or just slowly gaining over weeks and months, maybe they are gaining weight a little faster and maybe not getting much concern from anyone but still not growing on “their curve” or are they babies who are gaining weight exactly like we expect and on their appropriate growth chart. This matters! This is a very important factor. No one is checking this before performing a procedure. Babies with low weights, have low stamina and low appetite and don’t care to breastfeed better tongue tie or not, with or without a revision. If they go ahead and have a revision sometimes they start to refuse the breast when they have previously latched or just are still sloppy feeders, or tired feeders, frustrated feeders. I am really making sure this growth part gets figured out first. If we can get the weight up first and not just up but to their appropriate weight for age based on proper growth charts, then when they have a revision, they usually get it all sorted out much faster and kick compensations like nipple shields, supplements, nursing all the time, being at the breast to soothe or moms having to be particular about positions, etc. Each baby needs a unique plan to get to their weight up and that is a key piece of what I provide. A breastfeeding plan HAS to include something more than “just supplement after a feed”. It also has to have a plan to assess if function is regained after a revision or if there needs to be some work put into helping baby use the tongue and other facial muscles to feed. Again, an IBCLC who is skilled is vital to this. It is not just "suck training" like a finger or soother that is going to do this. There are so many actions and exercises to help. 
Now, when I get called after a revision, I can still help and we can get past these remaining pieces, it just is in reverse but I find it is a bit more stressful for moms and families because they also have a cranky baby and after care exercises to get in, and often pumping & supplementing as all. It is better when I can set it up as steps and one focus at a time. Once supply and weight is up, it is one less stress, so then they can handle the stress of the aftercare and extra needs of the baby.
If you suspect your baby has any sort of tie - tongue/lip - and are needing some help navigating it all, I am happy to be a resource for you. You can see more of what I offer for consultations here. 

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